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BUILDING DIVISION PERMIT
INFQRMATION
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BUILDING ADDRESS:
Isis MTTT?Am(-) rTR TOT -42
CENTEX HOMES
PERMITN0403011S
OWNER'S NAME:
PERMIT LS9UB DATE
CEN
ONE:
SANITARY NO. CONTROL NO.
925 415-1
RCHIIEC rEHGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am limmedi under proviuore or Chapter 9 (commencing
pion
fDivisionJoftW Basions andP%ns Cogs, endmylicenx is
Sectioned
in full fora and fife t.(Qi/J�
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ff
SFDWL-3 STORY (PLAN 2)
License CI Li.V
Dam c Contractor
LIVING 1753GARAGE 477 SQ FT
ARCHITECTS DECLARATION
1 uMersund my plans stall k used u public recmda
Licensed Pnafcssional
Oat
mDECLARATION
1 hominy .(Sere Not 1
I am exempt
cumpl tram dr Conuacmh License
from Law for the
moun
following mason. (Section 1117 LS, Business and Ra, cle a c
1. Code: Any city or county
which i li
improve, demolish, fi mash tatemme
a Permit t re cores
its issuance.do, aalter,pplicant
su ed
prior itsiensedprsurequires dokvisions or for such Permit o Ecarsle a , Law(Cha mem
NommencingwJpurstion7 Me,
Sq. FL Floor Area Va b�86
) ofDivioesorlheCmnsinesslaetsslaw(Cltapmr9
of Divisionr ofthe Cmk)ter
Any
that M incingwish ereforn and eged xsandon. vi
that he u exempt Orse(rom and the buts far Ne alleged eumpuon. Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant as a civil penalty of
not mom Nan five hundred dolbera($500),
APN Number
Occupancy e
p y Typ
01. as rofthepropcny, or my employees wish wall as their xlecompenuuon,
36619076.00
will do she work, and Ne structure is not immrrdcd or offered for aide (Sec. 100,1, Business
and Pmfessiom Codc: The Comacmr's License law dors tet apply as an Owner of
Required Inspections
pmpeny who Wilds in improve thereon, and whodoessuch work himselfor through his
rte, ri
Own employees, provided that such improvements are not Intended oroffcmd for sale. If,
Ne Wilding or improwmentuxldwiiinot of Ne owner-
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builder
builder will have the WN[o of proving that he did not Wild or improve for purpose of
efor
Wildimprove
t - l)
sait
❑ I, as owner of the property, am exclusively contracting wit liceesed contractors to
construct to project (Sec. 70". Business and Professions Code:) The Conuumts U.
T nL
cove Law dors not apply to an owner of property who Wilds or improves themon, and
J
who contracts for such projects with a conuactor(s) licensed pursuant to, the Contractor's
Licca law.
❑lam aempt under See B& P C for this
Owner Data
'LDJv '.
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimations:
have and will maintain a Certificate Of Consent x self-insuR for Wallace, Gompem
n, as provided for by Secuon 37W of de labor Cod, for to performance of the
rk for which this permit is issued.
1 have and will mainuln Workers Compnva en InsuranCe, as matuimd by Secuon
3 of Ne Labor Code, for Ne performance of Ne work for which this Permit is issued,
My Worker Campevau n lvuranee cortins and Policy number am:
Grtier/�%l� Policy No.: WG .1y�1 2ZOJ_
CERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not he completed if the permit is forone hundred dollars ($loot
or mos.)
I Certify Nat in Ne pmfomlanm of she work for which Nis permit is issued. I shall not
employ any person in any manner x u m become subject to Ne Workers' Commosation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making Nu Certificate of Exemption, you should
become subject m Ne Worker's Compensation provisions of the Labor Code, you mon
forthwith comply wish such Prwisimu at this permit shall k deemed rov akcd.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat thea is a connrucfinn lending agency, for Ne performance of
the work for which this permit is named (Sec. 3091, Civ, C.)
Undoes Name
Under's Address
1 rectify that I hats rtad Nis application and sum Nu Oe move ve information u
COMM 1 ague m comply wish all city and county ordinances and state taws mlating m
building construction, and hereby au imine representatives of this city to Color upon she
a Wa-ps ntioneJ properly for inspection purposes.
(We) agmen save, indemnify and kap harmless the City of Cupertino against
liabilities, judgments, costs and exposes which may in any way ucmc against said City
in cansegance of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
S f1RC R GUfATI NS
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Re -roofs
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51gnamm of Applt onuumr D'am
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will she applicant or future Wilding occupantsmre or handle hvardmus material
u defined by dm CUPenion Municipal Code. Chapter 9.13, and Ne Health and Safety
Code. Simon. n 25532(a)? XNO
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or devices which
't
If a roof is installed without first obtaining an inspection, I agree to remove
coava dow air contaminants ss defined by she Bay Area Air Quality Management
0
all new materials for inspection.
r ❑ Ycs 1]• NO
I have mail Ne Waardoue materials mquiromeats under Chapter 6.95 Of the Califor.
nix Half 6 SafetYCole. Secdues 35515, 35577 am125534. I understood dot if ft Wilding
Jon of currently haus a moan, that it is my resp readlity w mon ly the occupant of Nc
y c rah must bemct prior issuauc of a Ccnificam of cu y, i'
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Signature of Applicant
Date
All roof coverings to be Class "B" or better
Owner mraulho 6magent ' Dam