04030097 CITY OF CUPERTINOi=a���l�
BUILDING DIVISION PERMIT 000ONTRACTOR�I�NFO�kMA.TION
BUILDIN PERMIT NO.
CENTEX HOMES 04030097
OW NER'S NAME: PBRMR I$l18 DATE
' E:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
am LICENSED CONTRACTOR'S DECLARATION
I hereby Wind that I am Based under provisions of Chapter 9(commencing Job Description
wrath Section 7")of Division 3 of the Business and Pro@uluns Code,and my license,is
in full form and effect.
5 License Clue La.0 SFDWL-3 STORY (PLAN 5)
3e D,a T'S DECLARATION ARCHLIVING 1992/GARAGE 430 SQ FT
6`y fIEC on
I undersand my plans shall W used as public records
Licensed Pmfeukmal
OWNER.BUILDER DECLARATION
I battery effort that I em exempt from dre ConuenoYs License law for the
a 0 following mason.(Section 7101.5.Business and Profeui.as Code:Any city.r county
$ff which requires a Permit m mnsmrct.Aur,improve,demolbh,m mini'my madam
F to prior to its iu
iumue.also requires lbeapplicant forsuch pcmaiva Nm
rile sulccnt
brain is licensed pursuanuothe provisions.rumc.mtrmm.1-cens,Lw(CWpur9 Sq.Ft.Floor Area Va t
C0 (commencing with Section 7014)of Division 3ofNeBmu
incandProfessionsCode)or ff8700 -
33
that he la exempt therefrom and the basis for the alleged exemption Any violmlon of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of APN Number Occupancy e
not mane than five hundred dollars(5500). P Y TYP
1,at owner of the progeny,or my employees wish wages u their sok compensation. 36619076 . 00
will do the wast,and the muero t is not Intended or offered for salt(Sec.70/4.Business
and Profe.rrons Code:The Constitutes License Law dons ant apply to an owner of Required Inspections
property who Wilds or improves Nereon,and whodousech work himself.,through his
own employees.provided Net sech improvements isne n..tended apii:rtd for We l,. S
owne mp o e Wilding car Improvement is mid within enc year of completion,the owner. y(�p,,\j
builder will have da Wrden of proving Net he did not Wild or improve for purpose of
LED
CI I,u chime,of Ne property,am exclusively contracting with licensed conuaeurs be JUN 5
constructnse laNe project(See,7014,Business and Professions Code:)The Conmac s W. 1UU _
cew does not apply an an owner of property who Wilds or improv Eamon,ands
who contracts for such projects with a conuaclor(s)licensed personal 1.the Commander 1 p�\�fleff
Lt... BU'L®fd �9
01 a pt and Sm,/�yy—�� p —,B&P C for Nis naso
/'S C %PENS Da
WORKER'S COMPENSATION DECLARATI N
1 hereby a It under Penalty of perjury ane of Ne following declarations:
aw.nd will meinuin a CcAlfima of Consent mulbinsum fa Worker'SCompen-
on.as provided for by Section 3700 of the Labor Code.for the performance of Ee
w for which this Penni)is laurel
1 hove and will meimain Workers Compensation Insurance.u required by Section
3700 of Nc labor Codf,for the performance of the work for which this permit Is issued,
MyW., oro ns do Insmence"aier end Policy number ^D�
Cartier. Y�s�oai Policy No.:
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed Ifthe pdmit Is forma:Wndreddnlhn($1011)
or lea.)
I«nif-v Net in the perfn,maece of du work for which this permit is issued,l"I not
employ any person in any mannerm to to become subject to Ne Workers Cmnpenution
Laws of California.Dart
Applicem
NOTICE TO APPLICANT:IL afar making this Cenincau of ascreption,you should
become subject N Ne Workers Compensation provisions of the Labor Cede,you most
.J z foMwith comply with such provis mu or this permit shall be dmmed Ranked.
,z„O CONSTRUCTION LENDING AGENCY
Ihembyeffrm thn Nerc inaconstroctinn lending egerrcy lar Ne perfurmmcc of
Cithe work fur which this permit is Wood(Sec.3097,Civ.C.)
Y251<dces Name
=z Landers Address -
U O I certify dual 1 have red this application and sena that th:above information u
IG cootet.I agree to comply with all city and county ordinances and state bras relating to
0U building construction.and hereby summon,representatives of this city to cnarupen the
Uabove-mentioned property for inspection purposes.
(We)agree a saw,indemnify and keep harmless the City of Cupenino agalnsl
vF.,r W Iiabilidu,judgments,count and cateran which may in my way amu:against said City
U4in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH NON-POINT Issued by: Date Y
RE U TIONS.
Re-roofs
Si art of App�i andConumar Dau
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant or future building uccupantnom or handle Wmolous mumial
u defend by she Cupertino Mu 'Pal Code,Chapter 9.Ig,and the Health and Safety
use.s:dor nslx(.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu No
WIII the applicant to
Tutu wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hazardous air contsmin Is defined by the Bay Arca Air Quality Management all new materials for inspection.
Viet?
❑Yes No
I hew read Ne hua'dnu,.Mda]3 mquim=nu uodcr Clupar6.95 of du Califon
nuH alth&SActyCodc,Scaoas25505.25533 erRI25534.1uurimm dNalifthe Wilding
data not currently have a unmL that It Is my ruFeasibility to notify sheeccupant.f Eu
requiremcn ichor IWmciPnm mof.Caoilkaaof'nccy/ Signature of Applicant Date
e1.r mtm a
hongcm v —w /ma All roof coverings to be Class "B"or better