04080014 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR TNF®RMAION m.
t:-�IfPr_ �a.aril 3'2 ?ds ��
BUILDING ADDRESS: CENTEX HOMES PERMITNO04080014
RTANrHTNT TV TOT 2R
OWNER'S NAME: PERMITISSUEDATE
11/24/
E; SANRARY O. ONTROL NO.
(925) 415-1600
ARCHMICTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uOp LICENSED CONTRACTOR'S DECLARATION Job Description
C 1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing P
b with Sccdon]IXXB of Division3ofdrc Businru asq Profuaiou Code.and myliccnscis
^�,� in full Tome and effect.
License Class Lk.p REVISION--DEFERRED TRUSS
�—o Dar Contractor NO NEW PERMIT ISSUED/ORIG. $ 04030067
W ARCHf1ECT'S DECLARATION
<U I undersand my plus shall be=it as Public records
J
3w G Licensed Professional
OWNER-BUILDER DECLARATION
2 0 I hereby.(Sero Out I i. exempt from the Contest's Licem)taw co sed
20 following moan.(Sanson 7(Di.0.Business and Pte,dm R Code:Any city or county
m v with tequircs a permit re airs the alma impolite,demolish.of a pair ed swctule
FZv, prior mits censed e,alumquims theappliant forsuch Cmusrmiuo R4asLmdsummem
ESG thmbeis0cenxd pursuant 70th)of Divionsn(the eBusiness LicenseParliament
mens Capmr9 Sq.Ft. Floor Area Valuati0A 115
tel-
that
exemiNsection
romandth Dindion)MNeeged euand Professions Cade)of 4
$ Net be u exempt Incm(rom and the buns for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant m a civil penalty of APN Number Occupancy e
not mole N
an It.bundled dollars(5500). P Y TYP
❑I.uowar of tiro propenri amY employees with weguutbeir sole eompenution, 36619076 . 00
will do the wart,and the structure is not intended or offered for sale(Sec.704,1,Business
and Pmfessinm Code:The Culminates License Law dons not apply m an owar of Required Inspections
property who builds or improve thereon.and whodens such work himself ordirough his
own employees,pmvidcd thatsuch impm ourna u art not in odcd orolfued foru4.It,
howewn the building or improvement is sold within one year of completion.the owner.
Witcher will haw the burden of proving that W did nor Wild or improve for purpose of
V4 .
1,u owner of the property,am exclusively nonbacting with licensed contraction;in
met the Project(See 7044,Business and Profusions code:)The Conmemes Li-
cerue taw dons not apply as an owner of property who Wilds or implants dialect,and
who concocts for such projects with a eonmctons)licensed pursuant to the Conmactoes
Lkens scot
❑lamexcmpt do ce. ,Bk PCfa sleuon
at D.teL� L
WORKER'S COM COMPENSATION DECLigRAT10N
I hereby alarm under penalty of perjury oa of allowing declarations:
haw cad will maintain aCertiBare cicatrices to salt-Insure for Worker'sf.'ampen-
sation,as provided for by Section 7]00 of the labor Code,for the Performance of the
walk for which this permit is issued.
❑1 have and will maintain Worker's Compensmmn Insurance,u required by Section
37M of no tabor Cade,for the Performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Polity number am:
Carrier. Policy No.: _
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This maim nod not W completed if the permit is faomhundred dallars(5100)
or 4ss)
I certify that in Inc Performance of the wells for which this permit H isso)d,I shall not
employ any Peron in any manner sa as m become subject 70 dm Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,aim,making this Cmifiam of Exemption,you should
become subject in the Worker's Compensation provisions of me Inbar Codc,you mus
.J z forthwith comply with such Provisions or this Permit shall be lamed mwked.
z CONSTRUCTION LENDING AGENCY
I hereby from that ft.is a construction lending agency far tiro ltertanne.of
!Yi me work fur which this permit is issued(Sec.3097,Cie Q
IW Q Lenders Name
G
z lender's Address
7
(„)Q 1ttteem atIMw rcd leisty anationandsum Intithend aWwim elating is
0 U correct 1 agree m comply with all city and county ordinances and state laws musing m
�U .1arn-gctnated prefand hereby anthon Purposes. of this city In enter upon Um
r� aWve.memioncd Property for inspection Purposes. /`'—�/�ff.IT�/
(We)agree to sew,indemnify and kap harrnless me City of Cupertino against
F'fq liabilities.judgments,costs and exp)nses which may in any way accrue against sold City
U z in comequemc of me gran' g of this permit.
^ APPLIC R AND WILL COMPLY WITH ALL NO -POINT Issued by: Date
SOUR RE
U Re-roofs
HAZARDOUS
nuurc of AppliaDam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof J
WIII Inc a Coll or forum Wilding occupant some sand the
hazardous material
u deeded a Inc Cupertino unicipel Code.Chapter 9.12,and me H)alth and Safety
Code.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Will the applicant or future building occupant use equipment or d)viccs which If a roof is installed without first obtaining an inspection,I agree to remove
it havadaus air eonuminanq dcftned by the Bay Area Air Quality Management all new materials for inspection.
umiet? `,\,y/
❑Yes
1 haw red one hvadous ma ortalerequirements under Chapterb.95 of me Califor.
ala Habib Safety Cadc.Sections 25505,25533 and25534.I understood mu ifthe Wilding
dors not ens dl(fv ice u} nt/het it u my responsibility u notify me occupant of the
rcyuimm a w' t 1/prior to issuance of a Ccmfica
Signature of Applicant Dale
Owner.1 mdurmed agcm —�' DateAll roof coverings to be Class "B"or better