04030096 CITY OF CUPERTINO
_.
BUILDING DIVISION PEF T CONT
MIAX TDRAN,FORMATION
BUILOINGADDRESS: 'Q N CENTEX HOMES """'04030096
o
ER'S NAME: PERMITISUEDATE
CENTEX HOMES3210212
2527 CAMTNO PAMnN #100 ONE: O.SANITARY NCONTROL NO.
(925) 415-1600
ARCHITECT/ENGINEER:
BUILDING PERMITINEO
' BLDG ELECT PLUMB MECH
u0p LICENSED CONTRACTOR'S DECLARATION IObDe5Cf1 Description
x U 1 hemby affirm that 1 am licenac1 under provisions of f]upms 9(commencing p -
halalSec9dmmnMdmyp1
Buuceex crap Ad s dc.a licensois
'r�N inmufSFDWli-3" STORY (PLAN $)' _
jtaZ LI[Cnha c.M
ARCTSDECLARATION LIVING 1992 GARAGE 430 SQ FT
�i Ie used as pontic records -
;a� Licenced Professional
3 OWNER-BUILDER DECLARATION
iI I lobby Affirm the'I em exempt form Ne Contractor's LicenseLaw for the
O O following moor(Scci un 71131.5.Business and Pmfcuiae Cork:Any city or county
K m V which requires a permit to construct,eller.Impmw,demeliN.or midair any structure
Fly prior to its issuance,also mquims the applicant forsuch pemulto Gla a signed statement. f.tsm
s<
that be is licensed pursuant to the provisions of the Contractor's benne law(Chap=9 .- .._ Sq.Ft. Floor Area V N1700
¢t-a (commencing with Section 7")of Divkion J of the Business end Professions Code)or -
O F F Nat M is exempt therefrom and the bask for He alleged exemption.Any violation of
Sation]031.5 by any applianl fo a pesmis subject me applicant to a civil penalty of APN Number Occupancy Type
net re Nan Rw hundred doom(ssm). P Y YP
I,asowns of the pmpmy,omy cmployeu with weguasNeir sole compenuuon, 36619076 . 00
do thework,end the xumctumisnotinrtnded oraw dofoul apply ]016,Bminess
and Pmretiana code:Th wsftmora ware Law ares Out apply lf rt rough is Required Inspections
pme eny who builds orimprovu Hereon,end who doe such ooh himcecred portals.
oough his
own employers.provided that such impmwmw t m not inteeded oroQemd for mner,
however.the building or improvementishathwithinoro yeas of completion.the pose of
builder will low the burden of proving that he did not bulk w improv for purpose of
ask.).
1,u owner of the popenY,am ucleiwly emevomling with liconsed con.mers As
consumer Ne project(Sec.7014.Business and Professions Code:)The Ci n racurea Li-
censeLawit=not apply tu an o Win or porpeny who Wilds m impmm thereon,and. -
whoconwcsforsuchporjecuwimacomnetor(s)licensed punumm to the Conaacror's -
License Law.
❑I am exempt under See .B h PC for this mason __-
er Dare _
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
❑I haw and will maintain aCenriicamof Canaenuoul6i.umronw.he.compen- - - —'—'� -- - - - -
sation,ax provided for by Secure 3100 of the Labor Code,for the perfotmana of the
work for which His permit is issued.
[]1 have and will maintain Worker's Compensation Insurance.as required by Section
3700 of Ne bor Crum.for on performance of Ne work for which this permit is iaswd.
My W ens pensatims Insurance eartier and Policy umber am: .-a A/y�
Carrie �/%L_Policy No.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Chis section need not be complemd if the permit is forone hundred dollen($LOB)
or Icsa.)
L unify that in Nc performance,of the work for which His permit is issucd,1 shall not
employ any pwcen in any memento as N bosoms wbjur to the WorkersCompensation
laws of California.Dart
Applicant
NOTICE TO APPLICANT:If,after making this CeniOcam of Exemption,you should
become subject to the Worker's Compensation provisions of the labor Code,you must
.J z (Othw0h comply with such pfoviuona or this Permit shall be deemed temked.
zCONSTRUCTION LENDING AGENCY
[-+ I hemley Affirm Nat there is a construction lending agency for me performance of
!Yr the work for which this permit is issucd(Sec.3099.Ci,C.)
Igl lender's Name -
z Lender's Add. �•' /-' --�
V Q 1 ttnee that 1 haw rod this application and duan Nn Ne show information isCOUCCL
IL Wilding
I agree to comply with all city and county ordinances Or and sus laws renting a
0 U bhow-mconaned pro and hembyaumorirercausesenuum of this city in error upon Nc
H yhow-mentioned property for inspection purposes.
(We)agow to sew,indemnify and keep hnmles the City of Cupertino ague'
Uh incoitiureecojudgments,costs and of this expenses which may in any way=me against mid City
Z APPLICAN ens ar the UNDERSTANDS
or A DWIFromIssued by:
Date
^ APPLICANT UNDE0.5TAND5 AND WILL COMPLY WITH ALL NON-POINT
AT ON -
Re-roofs
Ignatum ofApplm H C RDOUS MATERIALS DISCLOSURE °art Type of Roof
Will the applicant of future building occupant slow or Itandle haardous mamrial
as defined by the Cupertino Municipal Code,Chapter 9.12.and the Hulth and Safety
ronde,Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
Ye
Will the applicant or utum building occupant use cquipmenl or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdoud air cWuminams az distinct by the Bay Area Air Quality Management all new materials for inspection.
Disaict?
❑yu
Ihawreal thele,Scrims 25505,5533 m 25534,
55 under Chapter oflbe bldin,
ria HcalI banmaSafety fade,Scl 253rials, Jim 2553 mi Chaps r thnifNc Wilding
drca not curtcOil y haw•renters that it u my rcxporui " nuufy Nr a supero of An
myulre ta hmaisW tIs rmp(Or .dp� ' nature of Applicant Dale
wort w ainimmed agem Dart I All roof coverings to be Class "B"or better