04030089 CITY OF CUPERTINO - _-- - +' seta
BUILDING DIVISION . PERMIT CONTRACTORANF�O' RMA,T,ON „�, --------
BUILD INGADDRESS: CENTEX HOMES PERMIT"4030089 - -'--
ER'S NAME: PER 41T LSUE DATE
CENTEX HOMES
ONE: - SANITARY NO. CONTROL NO,
925 415-1nn
ARCHITEC"DENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTOWS DECLARATION JobDescri tion
aF I hereby affirm that I am licensed under provisions of Chapin 9(e.mmcncing P
i`� whb Sccuon7f1plyofD'visiod3of BmancssaMPmfeuand my is
a« in mumrt ndcrc SFDWL-3 STORY (PLAN 3)
S�b Lkense Cl ,g 7S l�
Dam _ Contractor LIVING 1809/GARAGE 430
? I understand my pins shall M d uARCH spubliccATION records
o
Licensed Professional -
3 Oat I am aU rept from
m the Cor ION O
0 0 I Maso ,Sere that 1 1. ucmpt Imre the Cssion Yd eLicense C law for drc 3 -
Kp o which following res;a Permit t 7co L9.Business and Professions Code:Any city m count'
m which acquires;a Permit m construct.alar,impmw,dcmnlixh,or repair any swcturt
u-'a primo,its ismaraw.alsu ospAra LMapplirICI forsuchpermitta file asigadstatemnt
izc thathcisliwnsoJpursuenuatMpmvisionsaftMComrutufSLianulaw(Chapter9 Sq.Ft. Floor Area /_ , <; Valuation
at (commencing with Section 7000)of Division 3 ofthe Business and Prolessinns Code)or - �?
$ Nat M is escmpt thadfrom and the basis for the ailegcd assumption.Any violation of $2,10700G
Satin 7031.5 by any applicant for It permit subjC,m the applicant to s civil penalty of APN Number - Occupancy Type
It are Nan Rw hundred dollar(5500). P y `]P
1,u owner of da pmpaty,n my employ=with wage as their role cnmpensadon,
illda Ne work end Nesweure u notimm�drA or.Read tarsale(Sa.7014,Busivss
Pwhcssiont Cada TM Canhnmr's uamse Law does Out apply to an awns of Required Inspections
propnywho Wilds or impraws darn.,and whodas suchworkhimalfa,thmugh his
own employees,provided that such i ri m ormo tt are not intended oro@ted forsale.If.
h.wewa.Ne building.,improvement is sold within ass year of nmphWn.Ne owncr-
Wildcr will hale the Wrdn of proving that he did nm Wild.r improw for putpase of -
ale.).
❑1,as miner of the property.w udusively conuacting with liamed coom urns On
Construct Ne projm(Sec.7014,Business and Professions Cade:)The Comracmr's U.
cove taw does not apply to an owner of propeny who Wilds or improve Namon.and.who contracts fm such projects with a contractor(s)liamed pursam to the Comramor's
License Law.
❑Iern esempt ad.See. Bk PC for Nis rearm
Dam
WORKER'S COMPENSATIONDECLARATION - _ -- -
1 Mrcby afgum mortar penalty of perjury arc of the following dalsruiov: .
I low and will maintain a Ccnifieam or Cansemuo alf-ivure for Wurkeh Campcn- - -- - -
sation,as provided fm by Secdan 3700 of this Labor Code.far the perfmmame of the
work for which this permit is issued. -
❑1 haw and will mainum Worker's Compevatlon Inuva ct,as rquimd by Secuen - - - -
37011 of the to or Code,for d0perfumtnce of the work for which this permit is issued. - - - -
My Wor s nmpemation�Ins/urantt�artier and Palicy//nnyy��mm//YMc _ d
Cartier. mm ti Policy No..
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
fruttratin nead.mhecumplemd iftbe permit is foram hundred dollars(SIW)
or less.)
I asdfy that in Ne performance of the work for which this Permit Ls issad,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of Califumia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenificate of Exemption,you should
become subject t.the Worker's Compensation previsions of dm Labor Codc,you most
.J'z faMwith Comply wit such pmvisiom or Nu permit sha11 be decreed hawked.
zCONSTRUCTION LENDING AGENCY
I hereby afurn Nat dart iso nmocunn Wtdmil a,me,far da perform an a of
2: the walk fur which this permit Is issued(Sec.3097,Civ.C.)
GQ Lendc,S Nam, -
z Lonskes Address
V Q I certify that 1 hen mad this application and sum Nat the,show information is --�
ly E^ cortC.L I agrn to comply with N city and county oolimm and,nate laws reladmg m
OU Wilding eamswctio.,and bembyauhorim romaduradws or this city to tour upon the
r G ahavomenuoned property for inspection puquses
(We)agree W saw.indemnify and kap harmless the City of Cupertino against
F'h in
of th,cosuang of this
may in any wayaccmc againstaid City
U z A cPLICANT of UNDERSTANDS
of this permit. /
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. "
Signature of n
ApplicVConDam Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding aeupnt amrc or handle haardom material
u defined by dte Cupertino Muni list Code.Chapter 9.12.and the Health and Safety
c,Otion 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
Ye Na
If a roof is installed without firs[obtainingan inspection,I agree to remove
Will the applicant or future wilding acupam tau equipment or devices which P g
emit Irvardnv air contamina as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
Yes
1 have mad the hevard,us maurud,rcq.i.mmma under C%mmr 6,95 car the Califor-
nia Hcahh d:5afcty Code,Sections 25505.25533 and 25534.1 mmenea d that tide Wilding
does not currently haw a tenant that it is my mspomibility m nouly da acupn1 of the
Q ichm be met I.I.. Confic.P00Cap Signature of Applicant Date /
0wnermmnh.rivnd ant O ,p,�m/� All roof coverings to be Class "B"or better (/