04030112 �'�
CTY OF CUPERTINO ''�r" j7' �'` " '
BUILDING DIVISION PERMITRAZIN �.
BUILDING ADDRESS: PERMIT NO.
CENTEX HOMES 04030112
OW NEI
0.'S NAME: PERMIT ISSUE OATH
E; SANITARY OL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�O p LICENSED CONTRACTOR'S DECLARATION O O O
t I hereby affirm that I am Handed under provisions of Chapter 9(commencing Job Description
rN Suetion]Oq))of Division lof the Budnme and Profusions Code,and my licence is _
in full fame and effect.
Z I�--�ppp Liccmc Clan Lre.n SFDWL-3 STORY (PLAN 2)
3q Data
Coo ARCHITECTS DECLARATION LIVING 1753/GARAGE 477 SQ FT
�uu�2�2 1 understand my plena shell he used u public records
i 7aU
e, Lkensad Professional
G
OWNER-BUILDER DECLARATION
i
q I hereby.filum Nn 1 am exunpt Imre do Cssime; c License Law for the
S:p O whicfolloh re moan. etch I IID I.S.uB,aiuo. and improve,
de ons Coda:Any city or runty
$ which rtquima n permit a construct,sac impress.demolish,at e a sig ed tuucmre
t- S^ pdarmits issuamaalso requires the
ovisio applicant forsuch Commonit to's
Law(mkmcm
< Ihmaisliccnudpunuenlmdm provisions of the Contracor'S Liccnsa law lChapmrY Sq.Ft.Floor Area Va tT286
(commencing with Section 7000)of Division 3 of the Business and Professions Ock)at yS L IJ tJ
$ Net he is emmpt themfrom and the boo for the alleged exemption.Any violation of
Section 7031.5 by a"applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mart Nan fist hundred dollars(5500).
L,sa owner nrthe 36619076 . 00
❑ proprny,umyemplayece womed!fos0otr sole 044,Bu.tion,
will do due work.and re,Curt is mol,Lica aur saw do fusaopply he a4, wner of Required Inspections
and Pmfw h ou Cade Th Conuxmr's Licence Lew dace or apply lf an owner or q P
propertyw rebuidmviimprovesch improvements
andwho aressuchwork mortared
his
awnemployees,provided pr smAimprm id wtsaenot ouofompledo .fu WeeIL
huweer,Neam,bugumor bero provinement g
did
noneyevorrompleforNeowner- FiIV�4l�
builder will low the Wrdm of proving Nat h did not bred or improv for purpose of
sale.).
❑I,as owner of Ih property,am esclusively convening with licensed mnuanors to
construct do project(Sec.7014,Business and Prefeesions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who Wilds or improves themor.and
who contracts for such pmjeco with a contnemr(s)licensed pursuant o ate commerce. 20 5
License law. t CJ Ovf
❑I/yayj�creptt onnQ'er Set ,B k P C for Nis retro
Obv
WORKERS COMPENSATION DECLARATION �UII
ILDING
thereby silica under penalty of perjury am of du following decorations:
haw end will maimain a Cenifiam of Consent m self-insum for Woher'eCompen-
,as provided for by Section 3700 of the Labor Code,for the performance of the
a for which this permit is lattice.
1 haw and will maintain Workers Compensation Imuran¢,as required by Section
3 blithe laWr Code,for the perfmmance of the woh forwhich this permit is essme.
my,rolke Campema' n Insumme camu and Politynu r art:
Cerise Policy No.: OS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thoacctim need not becomplmed If Ih Permit Is Intern hundred dollars(5100)
or Icss)
I certify that in the performance or the work for which this Permit is issued.I mall not
employ any person in any manmrso u in become subject to the Workeri'Compensedon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Cmiliicale of Exemption,you should
become Subject to one Workers Compensation provisions of Out Labor Code,you most
O forthwith comply with such provisions or this Permit shall h deemed revoked.
z'y CONSTRUCTION LENDING AGENCY
�.w Iareby al that Vert is a construction lending agency l'nr the perfurmane,of
a.moi
the work for which this permit is issued(Su.3097,Civ.C.)
W Q Lenders Name
z Lender's Address
U C 1 ceNfy Na I haw mad this application and sum that the show information is
correct.1 agme to comply with all city and county ordinances and more lawn relating to
DU building construction,and hereby authorimrepresentatiws of this city to enter upon ma
W ahow m odito d pmpcny for inspection purposes
a (We)agree to save,indemnify and leap lurml.de City or Cupertino against
fA liabilities,judgments,cods and experuu which may In any way seems against saidCity ��ss
U In consequence of Ne granting of this permit r y
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO -POINT Issued by: Date vv
U U ATI 5.
911(
Re-roofs
Signature of Applic4n onRDO Oare
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WiIINee C.partor m,fumrt building occupant Gore or Modich Health add
as defined by the Cupertino g/univmpal Code.Chapter 9.12,and Ne HctlN and Safety
Code,Section 15532(.)? J\N'/ All roofs shall be inspected prior to any roofing material being installed.
❑Yce No
Will the apPneml or mwrt btiuemg oectip,m use,egmpmem or aemmm winch If a roof is installed without first obtaining an inspection,I agree to remove
t hevardnus air cmnomi.1 Is defined by Ne Bey Arta Air Quality Manegemcnl all new materials for inspection.
icl?
❑Yoe u
1 haw mal the hamatums materiab requirements under ChsPor6.95 of Nc Califor-
niaHuad ra SafctyCode.Sections 25505,25533 and 25534.1 undersold that if the Wilding
once not comedy haw a onant,than it is my remonsihility m drolly Ne occupant of the
re me swmen tot's emptor nlleenirmarear0aen r. ignatureofApplicant Date
-" �� All roof coverings to be Class"B"or better
Owner or auNom ager Oso