04080011 CITY OF CUPERTINO ✓'BUILDING DIVISION DIVISION PERMIT r CONTRACTQR`INFORMA.TION`�'BUILDING ADDRESS: CENTEX�HOMES PERMIT NO.04080011
RTATq(-HTT\TT IN TOM 2F,
OWNER'S NAME: PERMIT iSSUE DATE
IS: SANITARY N . CONTROL NO.
(925) 415- 600
ARCHITECEIENGINEEB: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
C7 O � In
400 LICENSED CONTRACTOR'S DECLARATION
Z C 1 Mmby Ofssm Thum Ii
I accvM ns under provision of Chapter 9(commencing Job Description
<an n with Section? M))of Division 3 of the Business end Professions Code.and my license is
"o m in full forte and effect.
_qz tLicenm Class Lie.a REVISION--DEFERRED TURSS
—o Dam Contractor—
ARCHITECTS
untCL
ARCHITECTS DECLARATION NO NEW PERMIT ISSUED/ORIG. #04030062
££:
C I understand my plans shall W used as public meprds
adv
0 1 Lkcnud Professional -
OW NEm exempt
pER DECLARATION
.� 2 1 hereby affirm that 1 am ucmpl Item the Contractor's License Lew for the
00 following ressan.(Section 70 31.3,Buis;and Professions Code:Any city Or county
SE which requires a Permit in construct.almr,imprve,demolish.or repair any structure
poor In its issuance.also requiro the applicant for such permit to file a signed statement
Fc that hm
e is licc=d puant to the provisions of W Contractor's License Law(Chapter 9 Sq.FL Floor Area Valuatio$115
as (commencing wish Section?")of Division 3 of NC Business and Professions Code)w
F— that he is exempt thomfrom and the buts for use alleged exemption.Any violation of
Sued.7031.5 by arty applicant fora permit mbjem the applicant in s civil penalty of APN Number Occupancy T
not mom than five hundred dollars n5ro).
36619076 . 00
p y Ype
❑I,uawnu of the psopeny,Or my employees with wagesulhev sole compewdon,
will do the work and dommctuse is not intended or offered for sale(Sao.7061,Bulinus
and Professiom Code:The Contractor'Liceue Law does not apply to an owner of Required Inspections
propcny who Wilds orimprom thereon,and whodocssuchworkhimselforNmugh his
Own employees,provided that such improvements art not intended confined!forsas.It. ,
however.the building or improvement is sold within one year of completion.she owner.
builder will have Ihn basden of proving that M did not Wild or improve for purpose of
KI .
1.u owneru
of the property.am elusively contracting with licensed contractors to
con et dm pmjm(Sec.7044.Business and Professions Code:)The ContractWs Li
cent Law does not apply to an owner of property who Wilds or improver thereon,and
who comment for such project,with a contractor(s)licensed pursuns to the Contrasts
Lies.Law,
I am cx s PaC�fo{duration
r l�(s
WORKER'S COMPENSATION DB�W TION
1 hereby affirm under penalty of perjury ons,of she fallowing declarations:
have and will mountain aCeeifimam of Consent m mlf-insure for Workeh Compcn-
sstian,u provided for by Session 3TW of the labor Code,for the performama of dm
work for which this permit is issued.
❑I base and will maintain Worker's Compensation Insurance,as sequirtd by Section
37W of dm labor Code,for the performance of the work for which this permit is issued.
My Workefs Compensation Insurance carrier and Policy number art:
Cartier. Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectors need not he completed if the permit Is foronc hundred dollars($[W)
less)
I certify that in thc porfmmance of IW work for which this permit is issued,l shall not
employ any person in any mannerm u in become subject to dm Workma'CompcuxGon
Laws of California,Dam
APplicans
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
Woods mbje0 0 the Worker's Compensation provisions of um Lahr Code,you must
JO forthwith comply with such provisions of his permit shall be deemed revoked.
Z 14 CONSTRUCTION LENDING AGENCY
p:14 hereby affirm that them is a construction lending gency for the performance of
cd > be work for which Nis permit is issued(Sec.3W7,On,C.)
W. Landes Name
6
7 Z Lcnder's Address
U 0 1 certify Nal 1 have mad this application and some Nu the above infwmauan is
IL t--' wrest(.I ogre to comply with all city and county ordinances and state laws mining to
0U building convection,and hereby authoore mpmssommises of this city to cnmr upon the
13.1 above-menudgm judprogment.
costs
for inspection purpowhich m.
F gy (We)agree to save.indemnify and keep hefOueas the City Of Cupertino against
py in Crommosidu Ce OfthecosuandOfpcnsa which may in any wyattrue against mid City
C-3 z in carmsequence of the gransin6 of this permit.
^' APPLICANT ND STAN S D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE S. �//
I
Signaurc of Applican✓Contmtw Dam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or forum building Occupant more or handle haurdous mamtlal
u ciefncd by those Cupertino M icip Co&.Chapter 9.12,and the Heahh and Safety
Calc.Section 25532(a)? All roofs shall be inspected prior to an roofing material beim
❑Yea P P Y g g installed.
Will the applicant or future building occupant use equipment or&vice which If a roof is installed without first obtaining an inspection,I agree to remove
hvmdma air constraints nys u dcuncd by the Bay Ama Air Quality Management all new materials for inspection.
xuia? ;dV'1R7(u\a'dR-
❑Yes
Ihavcmadthehournam m oalsrryvirtmenu under Chapter6.95 afthe Califon
nice Hcolth&SafetyCOdc, uou25505,25533and2553 .1un&mm�dthairthe Wilding
doer nos Gunn hast a s it u my mrpomibilisy m nmury the Occupant or thc
mwimme - m turoom=araeemr¢ay gq (xggiJpey,. Signature of Applicant Date
Owne,yatithan.clagent nate All roof coverings to be Class"B"or better