04030113 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �aCONTRACTORINFORMATION -,i
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awLDING ADDRESS: CENTEX HOMES 111N`04030113
OW NER'S NAME: PERMIT ISSUE DATE
ONE: SANDARYNO. CONTROL NO.
CHI'IECrIENGINEER: BUILDING PERM INFO
BLDG ELECT PLUMB MECH
0 I� O O
LOO LICENSED CONTRACTOR'S DECLARATION
w 1 Mmby affirm tat 1 am licensed under provisions of Chapter 9(c mincing Job Description
_i with Section In )o Dirsion Sof the Busnrss and Pro a nseia
:^�„ Lfullfameande et SFDWL-3 STORY (PLAN 2)
�R License Class �� Lk.Y of �/ N
—� Dam contractor �� '7
Ef—
^� ARCH CT'1'SDEDECLARATON LIVING 1753/GARAGE 477 SQ FT
or Imulkuandmyplans shall Ise=it As public meet& ADD PLLONGRNGR FEES
a t; Licensed Profasai...I
s'm3 OWNER-BUILDER DECLARATION
.�<f 1 herchy from Nal I am ucmpt from the Contractors License taw for Me
ype following mazon.(Secuon 7031.5.Businessand Prefessmas Codc:Anyeltymooumy
a B g! which rot ims a permit,n construct,Iter,improve,demolish,.,repair any stmeltue
rzi prior in its iuu.cc,also mtion.lWappimant for such permit,.file a Iignedsutemem
< that W is licensed pursuant o the provisinm of Ne Contractors License Law(Chapter 9 Sq.Ft. Floor Area '"�Valuatiom V
(commencing with Seetion 710))of Division 3 of the Business and Prolminns Com)or 200286 .�.//
$ tat Wes exempt thumfmm and the basis for the alleged caemption.Any violation or
Section 7031.5 by any applicant for a permit subjects theapplicanuo a civil penally of APN Number Occu
ant a me tar five hundred dark.(scop). panty Type
I,u ownerof the nropmy,nemy.mptendedwithweedsasthcv sole 01M.Bsiness
will do the work,ands: lm 0masnot intended mattered d torula(Sec.Ilan,Business
Add Proart,who
Cade:The vea Memon, rid who law does or apply Iran owncr is Required Inspections
propertywbo s.proorimDmw thereon,and who are net intended
oroffredthmuen his
own employees.Me, iprovideddratsuch improvements arenot intendedm.ffercd ferule. r.
however else building or improvement is sold within one year or improv far the pore of
builder will have Me burden of proving Nat he did nct Wild m improve fu puryose of
ukJ.
❑1,as owner of Me property,am uclustmly contractingwith licensed conuactoa in
c.natrodl the project(Sec.7W,Business and Professions Code:)The Conuacmri U.
cenm taw does not apply In an owner of property who Wilds or improve daemon.and
who commem for such projeem with a commuctor(s)licensed pursuant ou IW Convectors
License Law.
❑1 am exempt under Sec ,B&P C for this mason
Owner Dale
WORKERS COMPENSATION DECLARATION
1 Wreby affirm under penalty of perjury one of the following declarations:
haw and will maintain a Cdrdficau ofConscnt As self-intim for WodursCompcn-
n,As,provided fm by Section 3700 of the labor Code,for Ne performance of the
for which this pemtit is issued.
1 have and will maintain Worker's Compensation Insurance,as mquired by Section
37 ofthclabWCo e,for Neperfotmanccoftheworkrorwhicbthispermitisiuued.
My Worjee amp aeon Wuance crier and poloy number. J/
Cam Polley No.�JC R3 2ZQ .Q
CERTIFICATE OF EXEMP TON FROM WORKERS'
COMPENSATION INSURANCE
QTs section need not W completed if the permit is for one hundred dollars($100)
IcssJ
I certify that in Ne perfntmanec of Ne work for which this permit is iuucd.1 shall not
employ any person in any mannerw As in bm.me subjects.the Workers'Compemation
taws of Califomis Date
Applicant
NOTICE TO APPLICANT:if,after making this Certificate Of ERemPllon,you should
become subject to the Wodmr's CounNumano Drmisiom of the labor Code.you most
Oforthwith comply with such provisions or this permit shall he deemed mvoked.
z'y CONSTRUCTION LENDING AGENCY
F" 1 humpy tlfrm Nat them iso ceutmction kndingegem,I.,the pc1orman.of
1' Mc work for which this permit Is issued(Sec.3097,Civ.C.)
1 Lender's Name
zLenderss
Lenders Addre
U0 I certify Nn I have mad this application and suss Nat the above information s
Li,Er toted 1 agree to comply with all city and county ordinances and auto laws rolating to
0U building construction,and hereby authonne rermsenmtiver of this city to enter upon the
W ahave-mentioned insanity for iupecuon purposes
pL (We)agree to uvc,indemmry and keep harmless Ne City or Cupertino against
rA) liabilities,judgments,cosuand cxlenses which may in any way accmc ag,insl said City
[)Z in comegmnce of Ne granting of this pcfmLL
^
APPLJCti,NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
= SOUR LA�ONS� iC '7�
Stgnalum ofAppsnnUUJJ'`'/n ivaaof . Dele Re-roofs
1rAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tW applicant or future Wilding occupant nom or bandit harudous material
M,defined by the Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
Code,pY s 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future Wilding Occupant ase equipment If a roof is installed without first obtaining an inspection,I agree to remove
PD g e 4 pmcnl or Mara which Qa
12�cr
tier, u air conuminanu u dcfincd by the Hay Area Air Quality Management all new materials for inspection.
Yea Jh'\rsa
I have mad the havardnusmamrials requimments under Chapkr6.95 ofthe Califon. /
Hulth&SafctyCode.Sectimu25505.25533 and 255X.1 undersand dw iftle Wilding
min currently have a u:mm,Na,it s my mspomibility b notify the occupsm of de
rim tB iasua� m.r Occup Signature of Applicant Date
.r,.m.nrcdag I D,m All roof coverings to be Class "B"or better