04080010 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �nCONT"CTOR INFORMATION•. ;
BUILDING ADDRESS: CENTEX HOMES PERMITNO.04080010
OWNER'S NAME: PERMIT ISSUE DATE
CENT
E: SANITARY NO. CONTROL NO,
25 4
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDGELECT PLUMB MECH
it" LICENSED CONTRACTOR'S DECLARATIONUW O O O O
C 1 hereby elRnn that I em licensed under provisions of Chaptermm
9(cacncing Job Description
to<U wish Section 7")af Division Sof the Businesssmall Pmfcs'um Cade,and my license is
infumufarcaand erca
License f Class Lic,N REVISION--DEFERRED TRUSS
0 z
�—o Dam contractor NO NEW PERMIT ISSUED ORIG. #04030061
�£ ARCHTIECTS DECLARATION
a' I understand my plans shall W died as public reconds
Jyia U
G� Licensed professional
g OWNER-BUILDER DECLARATION
1 Wrthy oRrm that 1 am exempt from the Comanor's License law for the
00 following mason.(Section 7031.5.Business and professions Code:Any city or county
x$� which ranches a permit to cnnsdm4 almr,impmve,dcmolush,fir rtpoir any swnurt
_zi poor to its issuance.also requires the applicant forsuch permit an file a signed statement
Yx that Ise isliccnudpursuanLLntheprovisionsOftheConiston'sLicenselaw(Chapter9 Sq.Ft. Floor Area Valuatio$115
aF (commencing with Section 7")of Division 3 of the Business and Professions Code)w
i Wt W u mal tMsefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy
not mod than five hundmd dollars(5500). P Y Type
01.as owner of the property,or my employam with wages u their sole compenadon, 36619076 . 00
will do the work.and dm swcmte is not intended or offered for ole(Sec.70th,Business
and Profeant.Code:The Committers Licence Law does tar apply Or an owner of Required Inspections
property who Wilds or ireprovesthercon,and who dassuch work himulfor through his
own employes,provided thatsueh improvements are,mtinmMcd orofAed for We.If,
however,she building or improvement is sold within one SIN of completion,the owner,
builder will have dm burden of proving that W did mon Wild or improve for purpose of
R.).
u owner of ct property,.Business
exclusively coffering wish licensed once Condamine,U.
c oo t the project seeapply
to an owner
of and Proproperty
who
Code:)The Cs themen,ti.
menu hoe docs not m as with
a of property who Wilds or improves Cotton,and
whocontractsLasts for such projects wish a contractor(s)licensed pursuant a the,Conuacmrl
License IiW.
U I an,ezempt /c�. —(/p—� B k P for this moon
ims
r// it A DaA�
SCOMPENSATION DECLARATION
I bercby affimt under pcoJty of perjury as of tW Icon declarations:
ve and will maintain aCenificxm of Conant to self-insure foe Worker's Compen.
provided for by Section 3700 of de Latest Cada for the performance of tha
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Inuvana,u no aned by Section
3700 of the la for the,performance of the work for which this permit is Canned.
,,AM11 y��—Worker' nm d as carrier and Policy num atf:.
sgfrtsy Polity
,-Q✓d •CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mia section need nothecamplemd lithe permit is barium hundred dollars(SIM)
or less)
1 cenify Nat in the performance of the work for which this permit is issued.l shall not
employ any person in any manner an u m Wsome abject to tW Worker'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you should
become subject in the Worker's Compensation pmvlaimw of the labor Cade,you must
.J O fonhwith comply with such provisions or this N.iuhall he dccmcd revoked.
Z CONSTRUCTION LENDING AGENCY
(-. I hereby affirm that Bert is a Conswction lending agency for the performance of
a she work fare which this permit u issued(Sec.X)D,Civ.C.)
aQ Lender's Name
=Z Londer's Address
U 0 1 cenify,Nat I have rad this application and sue that the a Wve information is
Ly gcorracL I agree to comply with all city and county ordinances and shim laws¢Irving to
0U Wilding conswction,and hereby auNarim represenutiv>s of this city to enter upon the
aWve-mentioned property for inspection purposes.
Lrt y (We)agree an save,indemnify and keep hatmlm the City of Cupcnino against
to judgmenaL espcnuamit. may in any way aecruc against aid City
U z APPLI consequence of thegmmin DS this permit.
^ APPLIC DERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
61 SOUR RE 0 501
. '�
Re-roofs /
519natims.FialiplicaratiCintract., Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will theapplicantarfu building occupant mart or handlehnudons mamoal
as defined by the Cupium ici�aI Code.Chapter 9.11,and the Health and Safety
Cudc,Section 25531(a)7
r]Yu All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I
Will she applicant or future Wilding Occupant esu equipment or devices which g agree to remove P
I hax ddus air cmuminanhi as dcfncd by IW Bay Arta Air Ounlity Management all new materials for inspection.
rsuict?
❑Yes o
Ihavereadthchaallowma ria lsreyuimmentsundcr .Chaper6.95ofthe Califor.
nix HcalNhSaf Cadc.S !c.25505.25533and255N.luMcrsu ifd¢Wilding
dors cot c n0y Our
a L m it m my mamnslhility m oodly de wcupvn of she
ughim rat. d m normiasuanaoracentrcateofaedp�Ey� SSignatureofApplicant Date
own d,edagem m All roof coverings to be Class "B"or better