04030110 ['U,�WING
TY OF CUPERTINO _ — - - ""? `� ^�+ •^"� ' `� "•p" s'
CONTRACTOR INFORMATION a
BUILDING DIVISION PERMIT gxmi so�°a 7.„_ �y a+'u e „ 1, ,ADDRFSs: CENTEX HOMES PERMITN1b4O30110503 MU
'ER'S NAME: PERMUT ISSUE DATE
CENTEX HOMES 2527 CAMINO RAMON 4100 12 /OR /2004
ONE: SANITARY NO. CONTROL NO.
(925) 415-1600
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CON71RAC1OR'S DECLARATION O O O O
enF I Wreby af0rm that I am licensee ander provisions ofCMpter 9 f m acing Job Description
Zty wiNSauo.7MO).lDVfid ofthc Bute"Ouertl Prp S esuy
icwcis n -
d in ruts three soda �( g. ,. SFDWL-3 STORY (PLAN 2) ; 1 -- --- — ----
ueeuse tie.g /� n
I - contractor LIVING 1753/GARAGE 477 SQ FT -
A CHIECTSDECLARATION R�
I uMersund my Plaine shall he used as PUMic rand; , f'
> J
3 0 Licensed Pofcssionel -- _
5 OWNER-BUILDER DECLARATION
I I hereby aRrm that 11. uusin from the Contractors e:Any
Law for the -
[10 following reason.(Satiun 710 1.5,Business and Professions Code:Any city or county -
y_ pooch requirea permit re eonsmee a@q improve,h permit to
nr a pair ed ;mature `� I f •( `I'��
I-z> Prioler inisissuance.imdpuemm unifes movisiocatiftheut uchpetor'sicense Law pChumcnt _
� < mmWtslicevcd OSmti,mto thepmvisinnsmtWCanuacmr's Licensclew(Codle)9 Sq.FI. Floor Area `�V [1Q�21a6
�$ that(emhe s account
it thereinto,
andi of basis n 3ON,W Bue casco d on.ProM vi Code)or �(,
-
that he ts exemDt mcrefrmo atW Ne buts far me alleged exrmPtion.MY violation of \� ?
Sermon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ane APN Number - Occupancy e
not m man 0w hundred dollar,(aces). P Y�'P
I,as miner of me popeny,amy employees wim wagesss Meir sok compensation, - - 36619076 . 00
illdo the work and thesbmctum ts not hounded m offered forest.(Sec.7014,Business
Professions Cade:Toe Conuxmri License Law does not apply an an owner of Required Inspections
Property who builds or imposes demon,and who does such week himself or¢rough his
own employee,provided mat such improvements are not intended croQered forsale.If.
however,the building or improvement is sold within one year of compaction,the owner.
Wilder will have the burden of Moving that he did not Wild or improve for purpose of
sale.).
El I,as weer of the pmpny,am exclunwly contracting with licensed concocts",in
construct One project(See.7044.Business and Professions Code:)The Comremmrh U.
cane Law doe not apply in an owner or property who builds or improves mere¢,and. - -who conuacu fm surd projects wim acommictoKs)licensed pursuant m the Conmactons -
Lueme Le W. -
❑IameaemptundmSec. ,B k P C for the reason .--
Date
WORKER'S COMPENSATION DECLARATION
1 hemby alBm under pnalty of perjury one of tie following dalaruions:
Ihew and will meinuina Cedfiou of Conscmmself-insure fw Workeri Compen- -- -- - - -- - _
cation,as provided fee by Section 3700 of me tabor Code,for the performance of the
work for which this permit is issued. - -
0 1 hive and will maintain Workers Compensation Insurut¢,ss required by Section -
3700ofinelabor Code,forme prtormarmcofthewmkforwhichmispermitisissued. -- - --- —. .-_
My Wor mrpc..Non In canna carrier and Policy n/u'mb�er/ay-e_
artier. Polity No.:L (O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This senior need not hecomphood ifthe Permit is formic hundred dollars(SIM) _
or less.)
I cedfy Nat in One performance of the work for which this permit is issued.l shall out -
employ any Person in any manner so as to become subject o the Workcri Compensation .
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Cenilicau or Esemption,you should
become Subject se the Workers Compensation Provisions of tW Labor cedc.you most
z, foMwith comply with such Provisions or this Permit shall W domed revoked.
z� CONSTRUCTION LENDING AGENCY
(-+ 11") I hereby aMo.Wt there is is consuuctimn lending ageney for tie peHorm sum or
ai the work for which this permit is issued(Site.3097,Civ.C.)
QLender's Name -
z lender's Address
U O I eedfy but I have fend this application and smN that me aWve Inromlad..is
IL f-' CO=L 1 agree in comply with all city and county ordinances and sou laws relating to
C)U Wilding consuutlion,and hereby aumonrc rtpmscnoldrOs Of this city to enter upon me
W aowa-mcntioncd property for inspection purposes.
1 (We,)agree man.indemnify and keep harmless ft City of Cupertino;gait¢ �/`^�J KJV
y
liabilities,judgments.costs and expenses which may in any way accnsc against mid City
Uz in consequence of me grSuting of this Permit.it.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT I Ued by: Date
SOU S
Sig...of ApplicanUConyy Mau Re-roofs
HAZgittl0U5 MATERIALS DISCLOSURE Type of Roof
Will IWapplicantorfactum Wildingoaupamsaltorhandlehwa monasterial
as dcnncd by the Cupen no�+ ni'pal Code.Chapter 9.12.and she Health and Sdcty
c.Set 35333(a)? 1� All roofs shall be inspected prior to any roofing material being installed.
❑
Ys No
If a roof is installed without first obtaining inspection,I
Will the applicant or rte m building Occupant use equipment or devices which g an agree to remove P
emit havardous air contaminants o defined by me Bay Area Air Quality Management all new materials for inspection.
Mount.?
Ihaownedmedc,See i.sNaisrequnot25underChapter G95ofine C.if.,
iia HcalthkSafcty Cade,Sations 25N)5.35533;¢125534.1 undersand motif the WiiJing
docs not eurend haw a¢none that it is my responsibility m surly ms acupam of the
re ire ,m he et miss¢ mr.c - Occupancy. _ natureofAppll nt Date r
Owner or amhmircd agent �DDaa'`u-O!� All roof coverings to be Class„Bat or better CG