04030114 CITY OF CUPERTINO
BUILDING DIVISION PERMITCONTRAC�"TORINFORMATION
BUILDINGADDRESS: CENTEX HOMES PERMIT ND04030114
OWNER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
RCHITECnENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMR MECH
a 00 LICENSED CONTRACTOR'S DECLARATION Job Description
O O O
u❑ 1 homey vlrirm that 1 am limracd under provisions of Chapter 9(commencing l3
WwidiSection70f0)of Dpi ision3ofthc Businessand ofcssinu Codc and yticcmazu
��„ mmnmmand_gll�r�/a_ �j�� / SFDWL-3 STORY (PLAN 2)
j�Z License Class Lic.0
Dam Contractor LIVING 1753/GARAGE 477 SQ FT
,e ARCHITECTS DECLARATION
y w cited understand my plans shall W d public receive,
U
6
''G so Licenud Pmfessiunal
5 OWNER-BUILDER DECLARATION
<� I hcmhy affirm that I am exempt from de,Conlrulors License Law for the
00 following mason.(Sued..71A 1.5,Business and ProRsrions Cale:Any city ar county
$ which requires a Permit to construct,eller,improve,demolish.or minor any inucem
prior to its iuumei also requires the applicant for such permit to file a signed statement
that he is licensed pursuanuo the provisions of the Contractor's license Law(Chaper 9 Sq.Ft.Floor Area 1HSLits+s286
$ mormmeneing with Section 7000)of Division 3 of the Business and Pmrosions CodV"bV-
e)or
- that he is exempt dcrefmm and the basis for the Alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects the Applicant o a civil penalty of APN Number Occupancy Type
not mom than Five hundred dollars(MW). P Y YP
❑I.uwxrofdm propmy,mmy cmploycu wiN wages utheir sole compcneadon, 36619076 . 00
will do the work.and the structure is not intended or offered leom a(See.7061.Business
and Professions Code:The Container's License Law does not apply to an owner of Required Inspections
property who Wildsorimproves dsmoo,and who doessuch work himselforthrough his
own employees,provided that such Improvements ere not intended.roRered rename.If.
however,the,building or improvement is sold within one year of completion.the owner-
builder will have the burdrn of proving that he did not build or improve for purpose of
sale.). P n n
1,a owm,of the '� r Zj r-
❑ property,.Bump.Add Aoencting Co litteredomach ns m
ce mu�t the es not (Sec.71X4.owner
of and Nofesoans Code:)The Conuxen.Lid
cents law does not apply a an owns of property who Wilda or improves thereon.and
who mntraca for projects with a convsmr(a)licensed pursue in the Contractor's
Licalow. I 1..
E]I am
exempt under See. ,B&P C for this rcasen
Owner Date �._� (y��r
'
WORKER'SCOMPENSATIONDECI RATION
Ihereby afnm,under penalty of perjury am of the following declaratiom:
h' and will munuina Certificate of Comemwself-insure for Workeh Compcn-
u provided for by Section 3700 of the hien Code.for the podoream.of the -J
it on which this permit is Ismail.
I have and will maintain Workers Compensation Insurance,u required by Section
7 of NC lobar Code.for the peAormanccofthe work for which Oispemtitis issmd. /
My WorkAerC.m/peyryy�tion�I aria alien and Policy num rem:
Co.. N l"e t� l Policy No.:
CERTIFICATE OF EKEMPnOIN FROM WORKERS'
COMPENSATION INSURANCE
flhu seconstruct!not he completed Kthc permit Is for ane hundmd doilm(5100)
ar less.)
I comfy that in the perlaeance of the work for which this permit is issued.I shall not
employ any person in any mortician As to become subject to the Workers Compmer ion
Lows of Califomia Data
Applicant
NOTICE TO APPLICANT.If,after making this Ccniriimm of Exception,you shoulti
become subject to the Workeo's Compcuadon provisions of the tabor Cuum you roue
.,O forthwith comply with such provisions or Nis permil shall he deemed revoked.
z ti CONSTRUCTION LENDING AGENCY
Ihereby Aff.that Nue ism construction lending agency,for the performance.(
C the work for which this permit is issued(Sec.3097,Civ.C.)
fz1 Lender's Name
Lemiri Address
a Z
U Q 1 tinily that 1 have mad Nis application and sate that the shore information is
IL Pcon"M 1 agree to comply with all city and county oNiuraes and sum laws miming to
O V building construction.and hereby mthorlue reprcsemadvea of this city in Amer upon the
above-mentioned ms.propertyas for inspection purposes.
H y (WC)agree to save.indemnify and keep hamdeu di,City of Cupertino Against
Z inconsequence fOcgratsand evpcuuwhich may in Any way acme agvinn said City
t.)Z i consequence of thin graining of this permit.
AP ANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ..'R L O --------J: f/
✓{rgnatac of AppLmn mmenor ] Date O� Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the appl/c......
nt of.ulum building Occupant store or handle hazardous material
u dell d by the Cupertino Municipal Cote Chapter 9.12.and the Hcalth and Safety
Calc. out 25512(a)?
El Yea All roofs shall be inspected prior to any roofing material being installed.
N.
Will Nin applicant or future building occupant use c ai If a roof is installed without first obtainingan inspection,I agree to remove
y proem in devices which
10--olcomohonxtda
t haramuus air contaminants u de5ned by the Bay Area Air Quality Management all new materials for inspection.
Din? `//
❑Ycs ❑f.
1 have mad the haaarduusmaterials myvircments under Chapter&95 of the Califor-
Health&SafetyCode,Scetiaa 255)5.25533 and 25534.1 understand this if the Wilding
Out currently hart a tenane that u my respo ilii ldnotify the asupan f NC
. g"C/h-roman ctpI miaavaOc ; 'ha,teora � ignatureofApplicant Date
of
Do( All roof coverings to be Class "B"or better