04030088 CITY OF CUPERTINO
BUILDING DIVISION PERMIT "CON>TRACTaR INF®
RMATION
LBu1LDINOAD0RESS; CENTEX HOMES """'%4030088'PER'S NAME: PERFITT ISSUE DATE
CENTEX HOMES
ONE: SANRARY NO. CONTROL NO.
(925) 415-1600
ARCHDECT`ENGINEER: BUILDING PERMIT INFO
BLDG ELECF PLUMB MECH
0 0 0 0
40p LICENSED CONnsed unOWS rpooriDECLARATION lob Description
I hmeby affirm Net 1 em licensed under pup, cos of Chapter 9(rommcnrina P
with Section 70(IU)ofDiv'io of then Businee and Pr ".=iunx Co and my" seis
„ inrmlrmeenaerr SFDWL-3 STORY (PLAN 3)
�pz licenm cl Ix.g
AR TIEC�sDEcm1.ARATION LIVING 1809/GARAGE 430 SQ. FT.
w U I understand my plans shall W used as public mounds
to
Gt; Licensed professional '
3 OWNER-BUILDER DECLARATION
�f I hereby affirm that I am exempt from die Conlrecuse.Uccnu Law for Ne
O O following mason.(Smdon 7rn 1.5,Business and ProfeW..Coda:Any city or county
$ff which mquirca a permit to construct,sher.improve,dcmnR h,or repair my suucmm -
in prior to its issuance,also mquims the applicant for such permit to Ric a signed stam.ent
Nal he is licensed pursuant In the provisions of the ConlimewesLcmse Lw Chapter 9 .. Sq.Ft. Floor Area Valuation
¢�$ (rommcrcing with Section 70M)of Division 3^f the Busiocasand Professor.Code)or
.. Nat he Is exempt abortion.and the them;for the alleged exemption.Any violathoo or $210700
Section]031.5 by any applicant for•permit subjects the applicant in a civil penally of APN Number Occupancy T
not oro than five It Mmd dollars(SSDOL P Y YPe
1,as owner of Nm propony,or my employees with wages m Their sole compensation,
i dothenworkend Nemucuebs Nu inlen orofferedforavle(SM.70 .Budi366 19 U 10
and Professions Codc:The Con ractori License law docs not apply to an owner of - U Required Inspections
property who builds or improves thereon,and who dona such work himself or through h;
rum employes.provided that such improvements sum notin ended oroffered for We.If.
however.the building or improvement is mid within one you of compkdon.the awner- y h
builder will have burden of proving that be did not Wild or improve fm purpose of - - -
We.). ft .a eft r
I,as owmr of the 1
❑ Seen .B sinesi and convaatins with IIce.W roiscnOrti-
ro.wn the project(Sec.]OCC,Business and Professions Code:)The Conuacmr,and.
wholawdocsnotapplyin anoss idsaofproperty who Wilds lirimprove IWmrcand
whonse Lace for such pmXns o'iNaconuanor(s)Iia.ed purtwntm be Contractors
License law. !3
❑fun exempt unticr Sec .B d:PC for N;meson
or Darc _ _ r✓ �f /,�,� (-
WORKERS COMPENSATION DWC RATION
I bercbye(tirm under Penalty of perjury one of the following decimations:
❑Ihave and willmdnuinaCenifiamof ConuntmselGinsurt for Wrrtcrs Compcn- _----- �� �,.
;tion, provided for by Secdrn 3]011 of Ne labor Code.far Ne performance of Ne
wrdr for
which this permit is issued.
❑1 have and will maintain Worker's Compensation I....as required by Section _
3700 of tic labor Code,for the peof^n^ma of the work for which his permit;issued.
My Wo CompensadmNnsu carrier and Policy number ace — D
Carrierr±% Policy -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE ,
(Thiesectum need not W completed ifthe permit is foronc hundred dollars(SIM)
or less)
1 certify Nat in Nc perfummoce of the work for which this pc.I,is issued.I shell not
employ any permn in my manner m as in become subject b tM Wort Compenazdon
Lawsof Califti.n.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Conifi.m of Exemption.you should
bero.e subject in the Workm's Compensation provisions of the Lahr Code,you must
.J O forthwith comply with such Provisions or Nu permit shag W deemed revolted.
Z h CONSTRUCTION LENDING AGENCY - -
'F+ Ipeachy-form Nat Nem;a construction kndi,ii,my for use perforarnceof
C the work for which his permit;issued(See.3097,Co.C.)
6W. Q lender's Name
z Lcndefs Address
V Q 1 cenifY that 1 have read Nis application and sale dual the above infimor m.n is
LL r• rotrom I agree In comply with all city and county ordinances and sme laws totaling in
❑U building construction,and hereby mNoriae mpbsenmims of this city in enter upon the
Idl sho c-memiuned property for inspection purposes
C (We)acme to save,indemnify and keep hemthess the City of Cupertinoegainsl
Uh Iiabilitles,judgmcnu.cosaandespe.cs which mayin anywayaccrvc agsinst raid City
z in or dic UNDERSTANDS
this permit. Issued by: Date
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
SOU RE CATIONS.
Re-roofs
SOU of Ap CALK . Dam
HA ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle haardo.material
as defined by then Cupertino Munitl I Code.Chapter 9.12.and the Health and Wely
e,oton 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
Yes No
Will the applicant or Rnu building nccuport use equipment or dcvicoa which If a roof is installed without first obtaining an inspection,I agree to remove
amh ha aroma air rona.inmtr dofined by the Bay Area Air Quality Management all new materials for inspection.
Diuria7
❑yes No
1 have mad Ne ha ardour materials mquim.ents under Chapter 6.95 of the Califor-
n;Health lit Safety Code,Sections 25505.25533 son 255X.I undemood don if he Wilding
docs rot currently have a more.that it is.my menemibiluy b mdty IW occupant of he
re LawIn h..IWmnprioraananceo amoraropmry. ignature of Applicant Dale
Owner tar authorimd-gem �2"Date
All roof coverings to be Class"B"or better V