04030078 CITY OF CUPEitTINO •�,
BUILDING Dlvis�oN PERMIT a C�N,x'R"t1-C 0RIN
BUILDING ADDRESS: - PERMIT NO.
CENTEXNHOMES 04030078
OWNER'S NAME: PERMIT ISSUE DATE
AWL
E:
SANITARY Q&tOL NO,
ARC HITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�o p LICENSED CONTRACTOR'S DECLARATION
fi 1 hereby.firm that i am Ranged under previsions of chapter 9(commencing Job Description
with soeian 7")11)o f Division 3 of dw Business and Professions Code,and my Hecrom is
in full force end efful.
De�nacl ce"uin. SFDWL-2 STORY (PLAN 1)
ARCHf1ECPSDECLARATION LIVING 1510/GARAGE 435 SQ FT
I undcrsund my plans shall W used ss public onards
�wyU
c Licensed Professional
Oat I am exempt
form
DECLARATION
iI 1 hereby affirm that 11. exempt from Ne Cssions Co License Law for 1W
p O following moron.(Scetion BD1.4 Business and improve.
do iom Cad,:Any city or roomy
$en which inquires a permit re,ores tiro alte.Improve,demolish,ter mpairmy structure
sapriormits issuance,alsorequires theapplicantforsuchpermit mice signed(Chapter!)
that he mornmencingmdpunuanlm0mofDieiommfthe Butror'sndProllaw(Cock)m Sq.F[.Floor Area V 141
$ (cat he is xemptb Scdirarn nd th basis n 3 of tbe alleged
exe pt on.Any vi Codc)of
..
that M V exempt dterefram and the buts Iw the alleged eumptimn.Any violation of '
Section 7031.5 by try applicant for a permit subjects the applicant to a civil proal y of APN Number Occupancy e
not more Nan ave hundred dollars($50)). P Y EYP
Lm meter oftbe ro 36619076 . 00
❑ t peny,aemy, alater,mwlthwagecu Nelruleumpenntion,
will do tha work,end theswclurt is natlntended ormaerctl forsale(Sa.7044,Business Required Inspections
and Profemimm Code:The Conuutor's License Law does not apply te an menu of yyg���yas +++���... *??�..,,,��eq p
am ertywho Wiprovidmprowtsthereogand wha Amnotitende himulfmrthmugh his
t fS�q
awover.tyeea,provida Nm uchimpmumenuarcne iearofcara@red formic.IL 'm `f
however,the building or improvement ie old within ane yev of completion,hammer.
builder will have tha burden of proving that he did nm build or Improve for purpose of -
salt.). aa,,�'
❑1,as owner of the propeng am exclusively contracting with licensed contractors m ��l�(sa � A05,
construct the project(Sec.7044,Business and Professions Coda:)The Convector's I.I. u'aJ 1,
come law dam not apply m an owner of property who Wilds or improves Naeon.and.
who
enseI contracts for such projects with acmntnemrD)Ilumed pursuant in lM Contractors ■ ■����'
C]Ire I. v$■fin■
❑lame funder C. .Bk PC for Nis retro
o Da11�g/v f .
WORKER' COMPENSATION DECLARAR�N
I hereby fon under penalty of perjury one of the�fdi owl/wing deturadone:
am and will maintain aCenifiwteofConsent mwlf-insure for WorkasCompea-
n,u provided for by Secdon 37011 of the labor Coca,for the performance of are
.or or which this permit is Issued,
I have and will mumein Workers Compensation Insurance,m required by Scotian
7)(of the labor Code,for the performance of the work for which Nis permit is issued.
yWwkces Com enstitio nsurancecarricrand Pollrynuq Wram:
Cartier.g? t�Poliry No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
GIm section mud not W completed If Ne permit is forms,hundred dollars($I00)
or IASL)
1 certify that in the Performance of dere work for which this permit is issued,I shall not
employ any person in any manner so As to become subject to the Workers'Compensation
Laws of Corona.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifimm of Exemption,you should -
became,subject m the Worker's Compensation previsions of the Labor Code.you must
Cr
fuMwith comply with each provisions or Nis permitehallbe deemed invoked.
,z.,55CONSTRUCTION LENDING AGENCY
[—i Iherehy affirm that them iso construction lendingagemy for the performer:.of
ai the.,it for which this Permit is issued(Sec.3097,Civ.C.)
aQ Lender's Name
r0 z Lenders Addnsm
U Q 1 certify that I have read this application and sum Nat the shove information is
{i.Fcorrect.I agree to comply wit all city and county ordinances and state laws relating In
V building consuuction,and hereby authorme representatives of this city to enter open am
W above-mentioned properly for inspection Purposes
LL (We)agrce to...indemnify and keep harmless the City of Cupertino agdmst
ql liebilidee udgm,nu,costs and expenses which may in any way accom againetmid City
in consequence of Nc rutin of this Y
U'GR B permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU ULATIONS.
Re-roofs
Signature rel'ApplicamenConuactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ser future building occupanlslmre or handle hmsrdws material
as defined by Nc Cupertino cipal Code.Chapter 9.11.sed the Health and Safety
ode,Section 25531(¢)? m All roofs shall be inspected prior to any roofing material being installed.
❑tics ❑Nu
Will Nc applicant a foe he building occupant m,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hermdoes air contaminants u ticrined by the Bay Ams Air Quality Management all new materials for inspection.
Viet?
❑tics ❑No
I have mad the hmerdl s riaIsmquimmcros umko Chapter5.95ofNcCalifer-
niaHeal"SafetyCodc,Secuom25505.25533 and 75534.1 und,rsWM thatifdm Wilding
data not cuncnily haw:a unapt.Neth u my responsibility be nmuly Nc occupant of thc
re uwhichmmtbe me dartol f A CcNfmatemr Osco ry Signature of Applicant Date l %
w rauthcHat agent aDate All roof coverings to be Class"B"or better l/