04030091 CITY OF CUPERTINO �`' -
BUILDING DIVISION PERMIT CONTRACTyO_R$INFORMATION_ -
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BUIInINGADDRESS: CENTEX HOMES PER""%4030091
ER'SNAME: PERMIT ISSUE DATE
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ONE: SANITARY NO. CONTROL NO.
ARCHIEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LOo LICENSED CONTRACTOR
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I heby affm I am licensed underpravisains of Chapterr 9(commencing Job Description—,-I, - nmbDivision Sofft Business aMPro(cstios Cock, Yli<etseh
_Zthat
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c in fall force andll and cff X
'gam a«rte aaa l L;e,, SFDWL-3 STORY (PLAN 3)
�o Dam Conuazmr LIVING 1809/GARAGE 430 SQ FT �a
,e ARCHITECTS DECLARATION
y I undcmand Any plans shall be used es public noxmda
D�u
Licensed Pmmssional ,
^ OWNER-BUILDER DECLARATION �' I
1 herchy affirm that I am exempt from the Contractor's License Law for IM
X00 O following mason.(Section]HS 1.5.Business and Prefauion Codc:Any city or county :J v
x m which mgaita A permit m construct,.Iter,improv'.demolish,or repair any stmewrt
w-'^ prior in its issuance,also require the applicant for such Permit o fie a signed statement
t?'< that h'is named Partum to the mvisions of the Comracters License law(Chapmr 9 Sq.FL Floor Area - Valuation
- 1- (commencing with Section 7")of Division 3 of the Business and Prafemians Code)or
.- that he u exempt therefrom and the basis for de alleged exemption.Any violation of $210700
Section 7031.5 by any appli.1 far Permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than five hundred dolhrs(5500). P Y YP
i.asowrmx.(the propcnY.amy employe wire wags asshev sole compewtion,
will do me work,and the auuctum u notimm�ded oroRmed forsale(Sec.]014,Busimss
and Profession Code:The Contractor',License Law does not apply to an owner of Required Inspections
property who builds.,improves thereon,and wh.dm.xCh work himself.,through his
own employees,pmvidcd that such improvements Am not intended ofoffemd for We.If.
however,the building or improvement is sold within on yea of completion.the owner.
builder will have the Wrden of proving mat he did nos Wild CA improve for purpose of
sal'.).
0 1,as owner of the property,am exclusively contracting with licensed convectors m
comwct the project(Sec.7044,Business and Profession Code:)The Co emcmes Li.
cense Law dote not apply to an owner of properly who Wilds or improv thereon,and.
who contracts for such projects wish,A eontractor(s)licensed pursuant m the Contractor`s
L'mave Law.
❑I am exempt under Sec. .B&P C for this reason
Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty,of perjury,ore of the following daluatimts: .
1 have and will maintain a Certificate ofConem to selbinsum for WorkersCompen-
mus,As pmvidcd for by Section 3700 of the labor Calc,for the performance of me
work for which this permit is issued.
have and will maintain Worker',Compensation Insuramou,as required by Secure
me labor Code.for the performance of the work for which this permit is issued.
My Worker`s penauoaJ�nsu/n/ytt Cartier and Policy number Am: ib
Carrier: / ✓J(ice/ Policy N..:/.f1G
CERTIFICATE OF EKEMPION FROM WORKERS'
COMPENSATION INSURANCE
(ihisxction coed not be cmnpleed if the permit u fmone hundred dollars(',IOD)
or less.)
1 certify Oct in the performance of the work for which thia permit h issued.I shall not
employ any person in any manmrso as to become Wiwi to me Workeri Compensdon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eacmption,You should
become subject to the Worker',Compensation previsions of the Labor Code,you must
.,O forthwith comply with such provisions or this senior shall bo deemed mucked.
z.. CONSTRUCTION LENDING AGENCY
I hereby Affirm that these is a cnnvuction lending agency for the performance of
a me work for which this permit is;issued(Sec.3097.Civ.C.)
aA lenders Name
:D z Lcodcr's Address
U C) I certify that I have rad oris application and sum that the show,infmma6.is
It,F coma.I agree to comply with all city and county onhnumesand sou laws mhsing s.
CU Wilding construction and hereby aumosim mposenutim of this city to Omer upon me
abovetmenum. dgm propertyor for Inspection purposes.
F y (We)agree m save,indemnify and keeP harmless me City of Cupertino against
fA incoisequeneor Onecosuancxpcmp which they In any way aortic against said City
C.3 z A APPLICANT
U DERSTtotaling of this permit
^ APPLICARNE U�DERSNANDS AND WILL COMPLY WITH ALL NON-POINT Is�ed-by: Date
lnD �a///V Re-roofs
ignaturc of Applic HVC. RDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will the applicant or fuum building occupant store or handIC huardaus maeual
As defined by the Cupenino Municipal Code.Chapter 9.12,and the Hcahh and Safety
c.Section 25532(x)? All roofs shall be inspected prior to any roofing material being installed.
Ei Yp
which
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or Future building aecupam use equipment or devices g P
All hazardous air ronr
lam ota As dcfncd by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes [ fu
(ham maJ the hvaNnus mamriab rcyvircmcnts under Chapmr6.95.fthc C.1,rm-
nja HcalthdSafctyCad',ScWon 23NI5.255JJ au125534.1 undcrstmW thatifthc Wilding
dao not eurtend,have A tenant.mat it h my rcapomibility m notify the occupant f dm
C"
w 'hm"d e, ' 'tot CIACenlfica /angy. Signature of Applicant Date
n'r or aum.mcda t Clam All roof coverings to be Class "B"or better
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