04030080 CITY OF CUPERTINO -
BUILDINGDIVISION 'PERMIT
BUIL DING ADDRESS: PERMIT NO.
CENTEX HOMES 04030080
q26 M1-OWNER'S NAME: TR- - PERMITLSSUEDATE
CRNTRX
E:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
+lop LICENSED CONTRACTOR'S DECLARATION lobDescri coon
in
1 hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
with Section 70(X)1 of Division 3 of the Business and Prefo siom Codd,aad my]team.ie
ray in full force and effect.
iMz LImm.Class ue.x SFDWL-2 STORY (PLAN 1)
Dam TSDECr LIVING 1510/GARAGE 435 SQ FT
QI.Q ARCHITECTS DECLARATION
iia 1 undersand my plans shall be used u public records
Ole I
it Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby affirm Nat 1 am exempt from lk Contractor's License Law for the
O O following reason.(Smuun]fD1.3,Business and Professivas Code:Any city or county
$(L which tequ res a Permit to construct.aline improve,demolish,or repair any structure
pnar to i¢iuuance,al..quires the applicant for such Permit to file a signed summent
£ < tMthdislicen.dpunuantmthdpmvisioneofthe Cumr.torh Licea.law(Chapter 9 Sq.Ft.Floor Area Va�3t1(]A141
y $ (commencing with Section 7")of Division 3 of Ne Businessand Professions Cnde)M 1 y3
that he is exempt therefrom and the basis for the alleged exemption.Any.vI lafon of
Section 7031.5 by any applicant for a permit subjects me applicant In•civil penalty of APN Number Occupancy e
am ma.men five hundred dollars(MOO).
P yTyp
❑I,as owner ofthe property,army employeas with miles u their rule compensation, 36619076 . 00
will do me wank,and the structure is notimended oroQered f rtealb(Sec.7116/.Business
and Professions Code:The Commetofs Licen.Law does not apply m in owner of A R Ins eCtlOn$
property who builds or impmssatbemooaedwhn doesauch work Mnselformmugh his FINAA p
own employees,provided that improvements are nolinm xled oro@red for We.If, �g @@
he...the building or improvement is said within one yeu of completion.the man.
I lailky will have the When of proving that he did mat build at improve for purpose of JUN N 7y^ 'Ct
as owner of the property,em exclusively contracting with limned cantmemra to J U • 200^
const t the project(Sec.7064.Business and Professions CedeO The Contractor's Lt.
ex.who Lawdoes notapply een ownerofpmpeny who Wilds orant to the thereon,and -
whonse Laces far such projects with a conuacmrts)Ilmnud pursuant m the Conmetole
[] I.Law.
❑ lam exerypPynderS T/ .DBIk PC for this uon
BUILDING
is mer /// ((�®/J
7.n..p.vid.df.hyS.U.n37M.fO.Ub.C�.f.mcKrfomancofthe WORK 'S COMPENSATION DECIdRA I
I hereby Nrrn under penalty o(perjory one of Ote following dedantions:
..and will maintain aCenifimmof Cnmenl to rel(insure for rformanceofthe
for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as required by Section
of the labor Code,for the performance of the work for which this permit is Issued.
or ompe satjon1 ran=earner and Policy number aro / ti �r. 1K�/ Policy No: aV
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not k completed if the permit Is for one hundred dollar(S laB
or lass.)
I certify mut in the Performance of me work for which this permit is issued.I shall not
employ any person in any mannerso as to become subject to the Worker'Compemation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should
bacteria subject to the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such provisions or this permit shall k deemed revoked.
,z.,55CONSTRUCTION LENDING AGENCY
Fr I hereby affirm that inert is a constructinn lending agemy for me Performance of
!X> the work for which this permit is issued(Sm.3097,Civ.C.)
GQ I.endcr1AddressName
z Lender's Address
V 0 1 ranee o that 1 have read this city
and county
and sum that and
aWve information is
F banding l agree ct comply with all city end county ominantts and sum laws r op in IncG�
Q V abovengcoaamactiogand hereby.than..preaenutitcs of this city to enter upon e
above-(We)agree
property for iaspecuon puemua
(We)agree to cove.Inde expenses
and keep hart in
the City ra Cupertino idatishadt
City
Z Iiabmoaque.c.of
grsuand ex tensas tiff. they in anyway ecmm against said City
t„)'G I.A consequence of me greeting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dat
SOURCE LATIONg. ���
� �= —�a�-/ Re-roofs.
Sig me ol'Applicant/C rtor em
If ARDOUSMATERIALSDISCLOSURE� Type of Roof
Will the applicant or future building occuparstore orhandlc he, us material
as de0ncd by the Cupertino Mpal Code,Chapter 9.I2,and me Hcelm and Safety
cede.se❑c,a,25532(a)1 Na All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which g
havardous air canuminanu defined by the Bay Area Air Quality Management all new materials for inspection.
trio?
/ ❑Yes No
1 have mW Ne hmaNnusmateriahrequimmcnuundcr Chepmrh95 of dte Califor-
maHealth&SafelyGoda,Sccuam25505,25533 and 25534.1 makeund muifmc Wilding -
does not currently have a tenutl,that it is my responsibility to nddl'y the occurrent of the
m me in which Must be MO(pnorwIM cufaccitificateaf coppey gnatureofApplicant Date
Own amW, d ascot 3ine All roof coverings to be Class"B"or better v