04030079 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT A CONTRAGT0R4NF,RMA'�I -' -
BUILDING ADDRESS: PERMIT N0,
CENTEX HOMES 04030079
atk�&Mpll�dief!!N! - PERMIT ISSUE DATE -
SANITARY OL NO.
ARCHITECT/ENGINEER: (92F)) 415 3:690 BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTOR'S DECLARATION lob DescriptionI
in^
u F 1 hereby affirm that I am liwnwd under provisions of Chapo:r 9(commencing - _ . : _. - -_-.
`uj with Scaion 70M)ofD'vision 3ofthc Busisrssand Professions Code. mylicenscis
,a in full forte and f �i '7
o�yz Liana cl Lk:a__ SFDWL-2 STORY (PLAN '1)
eLa�'3 °ate AR HITEC-IS DECLARATION LIVING 1510/GARAGE 435 SQ FT
wI understand my plans shall he sad m public records
Sot, Licensed Pmfcsamnal
` 3 OWNER-BUILDER DECLARATION
o 1 therapy offum Nam l I aexempt fru.the Commences License law for the
p o following moon.(Section 7(131.5,Bminaa and Pro@nsiom Code:Any city or county
K m E which requires a permit to comwm,iter,improve,demolish,Or repair any MCI..
m�'^ prior to its issuance,also requires do applicant forsuch permit to file a signed suemcm
Xi< that he is licensed pursuant ro me provisions of me Constri liana law(Chapter9 Sq.Ft. Floor Area Va Q
FIs. (commencing with Section 7")of Division 3 of me Business and Professions Code)or / 141
y Net he is exempt therefrom and the-0mis for the Weged c tempuon.Any violation of _
Section 7031.5byany applicant for permit subjects the applicant to a Civil penalty Of APN Number Occupancy Type.- ..
art more Nan live hundred dollars(M).
01.in owner of the property,m my employees with wages as mi sale compensadon, 36619076 . QO
will do dte work.and Be surctum is not intended or offered but safe(Stec.7044.Business Required Inspections -
and Professions Cede:The Commi Liccrue law does not apply u an owner of q P - -
pmperywho builds orimpmves thcreon,and whodmssuch workhimselfor through his -
own employcm,provided Nat such improvements ara mn intended oroffemd for sale,It. _
however,the building or improvementissold within one year ofcomplction,the owner-
builder will have the burden of proving that he did not Wild or improve for purpose of - J
see
1.as owner of the property,am exclusively contracting with licensed Contractors to
c eruct Ne pmjea(Sec.7044,Business and Professiom Code:)Tse Coamaors Li -
cense law docs not apply to an Owner of propeny who Wilds or improves demon,and
who contracts for such projects with a comractor(s)licensed pursuant to the Comracnces `
License Law. -
1 am exempt under See. ,B k P C for this season O
Owner Dae 4
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury One of the following declaroinns:
Mere and will maintain aCcnificalc of Consenuo self-insum fur Worker's Compen-
737M
n,m provided for by Section 37M of the labor Code,far the perfmma e,of the
for which this permit is issued.
have and will maintain Worker's Compensation Insurance.m required by Section
of the Labor Code,for the performance of the work for which this permit is issued.
Worker' COmpeslvonInsurance timierind Policy a rareier. 77G%'l Policy No.. u
CERTIFICATE OF EXEMPr10N FROM WORKERS'
COMPENSATION INSURANCE -
(Thisactionneednot ecompl.acdifthe permit is for one hundred dollars(SIM)
m less)
1 certify Nm in the perfnrmanee of the work for which this permit is iaued,151101 no
employ.., .on in any manner w as to become mbjcm to the Wofkef3 COmpensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:IL mer making Nu CcnlBcate of Exemption.you should
become subjeet to Ne Worker's Compensation previsions of the Labor Code,you am
.J 7, roMwith Comply with each previsions or this permit shall W domed etwhcd.
Z O CONSTRUCTION LENDING AGENCY
P-+ I hereby affirm that them is a construction lending agency for the perfurmance of
C> the work for which this permit is issued(See.3097,CO.C.)
fz1 A Lender's Name
�• Iendees Addtesa -
U C I certify that 1 haat read this application and sate that the above infom,atiun is
Ly F-' correct.l agree no comply with all city and county ordinances and state laws¢Irving to
DU building construction.and hereby authmim rcpescnutives of this city to cater upon the
r anove-mentioned property for Inspection purposes.
(~ 4. (We)agree to save,indemnify and keep hatless the City of Cupertino egaino
N Iimiliucs.judgments,costs and expenses which may in any way acaue Maim,said City i
U Z in comegmnee of the greening of this permit. _
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
R CAT ONS.
Re-roofs
Signature of Applic Crowbar Doc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding arvpanumrc or handle hrallous material
as defined by the Cupertino Municipal Code,Chapter i.12,and the Health and Safety
Code,Section 23532(.)? ��1 ��/ All roofs shall be inspected prior to any roofing material being installed.
❑Yes �Nu
Will mea licant rr m\t. builJin Occupant as equipment ar Jevicea which If a roof is installed without first obtaining an inspection,I agree to remove
pp s paArQ
I"ramous air conaminants m Jcfincd by the Bay Arta Air Quality Managcmcm all new materials for inspection.
svin?
❑Yes Nu
1 have read the"ramous materials requirements sea&,Chapter 6.95 of the Califm-
m.He.["Safety Code,Secures 25505.M533 and 25534.1 understand that ifnhe Wilding
does not curendy have a¢nano Nat it is my responsihility m matily thc.aupam of me
nam con ria
or Ce = Signature of Applicant Date
owner Cir authorized. D,te All roof coverings to be Class"B"or better