04080012 CITY OF CUPERTINO _ � +"•+ '�"' -" , =
BUILDING DIVISION PERMIT
'CONTRAC"TORR FORMATION
BUILDING ADDRESS: CENTEX HOMES PERMIT N0.O4O80O12
RTANrT4TMT TAT T-C)T ';)d
OWNER'S NAME: PERMIT LSSIiE DATE
CEN
E: SANITARY NO. CONTROL NO.
(925) 415-Lrnn
ARCHITECIyENGINEER: BUILDING PERMITINM
BLDG ELER PLUMB MECH
LOp LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 herebyffi
arm that 1 an IksW uunder pmvisio s of Chapter 9(cummcmo
ing
with Section 70(lo)of Division 3 of Ne Burne and Professions;Cock.and my license is
�Dn imm�romeaaderr«r. REVISION--DEFERRED TRUSS
mai License Class Lie.M
;-o Dam Contractor
DECLARATION NO NEW PERMIT ISSUED/ ORIG. #04030065
Ui understand my Plans Nall be used u public meords
GLicensed Pmressi...I
OWNER-BUILDER DECLARATION
1 hemhy affirm Nal I em uempt from the Conuattots License Law for the ro
p o following meson.(Section 7(131.5.Business and Professions Code:Any city Of County
x m_ which requires a permit m construct.filter,imp.,demolish.or repair any suuttmc
Fiy prior In its issuance,also requites Ne applicant for such Permit in file a signed statement
P � that be is licensed pursuant mtheProvisions oftheCantncmr'sLicense Law(Chrm,'9 Sq. Ft. Floor Area - otoslo$115
of (commencing with Section 7000)of Division 3 M the Business and Professions Cedt)or
cd $ that W is exempt therefrom and th buss for the alleged exemption.My violation of
Section 7031.5 by any applicant for a Permit subjects the appliCMt to a Civil penalty of APN Number ane Occu
net mom than five hundred dollen(5500). Occupancy Y Type
01.as ewrcs of the Property.or my employees with wages as their wle compensation, 36619076 . 00
will do the work,and theswaure is not intended or offered for sale(Sec.70W,Business
and Pmfeulons Cade:The m
Conctera License Law does not apply to in owner or Required Inspections
popery,who Wilds orimproves dteceon.and whodoessuch work himselfor through his
own employees,provided than such improvemenu mi intended mOffmad for We.If.
however,Ne building or improvement is sold within one year of completion,the owner.
builder and have the burden of proving that M did not Wild or impress for purpose of
X
as awrmrfthe property,amucluively contracting with licensed eonnraclars to
ct the projccr(Sec.7064.Buineu and Profession Code:)The Con onithes Li.
w docs not apply m an owner of property who Wilds or improves thereon,and.
onuacu for such pmjecu widua ontncrorp)licansed pumuantm Ne Convenors
License law.
of am car t unpf e _ .B @ RCJajreason
( f
WORKERS COMPENSATION OECLAR �
I hereby afrimt under penally of perjury one of the fallowing occlusions; ,
sew and will maintain a Certificate of Consent to self-insum for WorkersCompen-
si uan,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑T have and will maintain Worke's Compcuation Iuunrta.u required by Section
37W of the labor Code,for the performance of Ne work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number me
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed if the Permit isforonc hundmddollars($100)
or lcssJ
I certify dust in the pe,fum...of due work for which this permit is issued.I sMll or
employ any person in any manner so as in became subject o the Workers'COmpensauon
Laws of Califomis.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Esemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
roethwith comply with such provision or this Permit shall be deemed rewired.
'Z,..,'O CONSTRUCTION LENDING AGENCY
lheteby M.than then iso construction lendin for the rfurmammur
a Ute work for which Nu .) rc
permit is issued(Sec.J097,CO.CivC.)
4 z Lenders Nam.
=z Lender's Address
V Q 1 cerify that I haw read this application and state Nat the above information is
LL F COrmCL 1 agree to comply with all city and county ordinances and sum laws relating no
C) Funding construction,and hereby motariw mpresemuivss a(thia city to enter upon the
Z) abovemcnuoned PmpertY for andexpert es Purposes.
d (We)agree to saw,indemnify and keep harmless the City of Cupertino against
(rh Ilebiliues,Judgmcnu.cosodi 'expert...which may in anyway acCruc against said City
V rZ in consequence of Wongo isPe t.
^ APPLICANT q{R AN A WILL COMPLY WITH ALL N NT Issued by: Date
SOURCE R Ul./sYI NS, q
f Re-roofs
Si he of Applican✓Contractor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding occupant stem or handle havvdous material
as defined by the CupertinounicipaI Code,Chapter 9.12,and the Health and Safety
Code,Section 255320)?C]Yu All roofs shall be inspected prior to any roofing material being installed.
Will thc applicant or future building occupant use equipment If a roof is installed without first obtainingan inspection,I agree to remove
pP C p yu'Pmcnt or devices which P
tna ardoua air comuminfind a u az cfid by de Bay Area Air Quality Management all new materials for inspection.
min?
❑Yea
I Ww read the herardmssmaterialsmquimmenu under Chapter 6.95 of the Califor.
nia Hcaldu&S Cade, cu 25533and25534.1undcrsmndthazirthc Wilding
does trot cu WU a �n Na t u my mspomiM1ility m n Ute ypan1 of the
reporcmc 5 n usiu..racenir, f —A\ Signature of Applicant Date
Owner am0679dagent Date All roof coverings to be Class "B" or better