04030066FZ>
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CITY OF CUPERTINO
DIVISION PERNUT
3 CONTRACTQR'INI+'ORMATION
BUILDING
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BUILDING ADDRESS:
CENTEX HOMES
111ITNcb4030066
OWNER'S NAME:
PERMIT ISSUE DATE
CENTEX HOMES
E:
SANITARY NO. CONTROL NO.
925 415-1600
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
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Job Description
lcd under provisions of Clnp m 9 (co mencing
I hcmby affirm Ilial I amicenv
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with Secdon t")of Don 3.f lW Businesse PPfy(Issiuns eve is
and cf %
Licenlse01 cgx',
DWL-3 STORY (1836 SQ.FT. LIVING SPACE)
A RAGE 400 SQ FT ( PLAN 4 )
Dam Conus Cor
AR MICTS DEC ATION
I u derstmil my plenxehau W used as public rccnrm
REVISION --#04080013/#04080125 (PORCH DETAILS)
Licensed Professional
OWNER -BUILDER DECLARATION
T hereby sfrion that 1 am exempt from the Cmu icmts License Law for the
follnwing mason. (Suction 7031., Business and Professium Cale: Any city or County
which requires a permit to enm ucl, alter, improve, demolish, or repair any structure
prior to its issuance. also inquires the applicant for such permit to Ole a signed smmmenl
Oat he is liccmod pursuant to the pmvisiore of the Contractor's lJceom Law (Chapter 9
Sq. Ft. Floor Area Valuation
(commencing with Section 70)(1) of Division 3 of the Business and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption. Any violation of$220638FIAI
APN Number ancy Type
Section 703 1.5 by airy applicant for a permit subjects the Applicant o a civil penalty of
not more than Ow hundred dollars (5500).
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❑L.O.. o.neproperlMummnotinoy nsimus
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dwiffafssthcirsol.7o ,
nsakpply us
will Professionssan Budrcss
r mesion, endthe he Con ranorinmaeder Law clues
end oro Cas: The Contractor's License law aces Icor apply ll an owner of
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ed n pDGllOn$O
erty wh won himalfor dtrough his
enywho Wilds
himprovndwW
Oat sues
Own provided are not in moRrsed foralen-
own employers, provided then such improvements are not ear
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cd c
huilder. Nebuilding orimprovementiasolt withinarcyearofcompletion,theewrcr-
builder will have Inc Widen of proving Net he did not Wild or improve for purpose of
sale.).
❑ 1. as owner of the property. sin exclusively convecting with licensed Contractors in
•'f
consumer the pmjecl (Sec. 7044. Business and Professions Code:) The Convector's Li.
\`h
Cents law does not apply to an owner of properly who Wilds or improves thereon, and
who contracts for such projects with a eonuacmr(s) licensed pureuant to the Contradoh
License law.
❑ I am exempt under Sec. , B & P C for this moron
Owns Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following declarations:
10
I have and will maintain a Certificate of Conant to self -insure for WorkersCOmpen-
satien, as provided for by Section 37M of the labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 ofelN�c Labor Code, for the performance of me work for which this permit is issued.
My W. n G
man lesunn niuPoli,
and � OT
Camcc!//o N.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE.
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(TTu section nem not W completed Ethe Permit is froom hundred dollars (SIM)
or less.)
I curtly that in me perfirmance of the won for which this permit is issued. I shell nut
trophy any proven in any manner se ar In WCnme Subject to the WenkcR Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Co nlimislion previsions of the labor Cade, you mut
forthwith comply with such provisions or this permit shall be deemed ¢voted.
CONSTRUCTION LENDING AGENCY
1 hereby affirm mal inert is a Construction lending agency for the performence of
me work for which this permit is issued (Sec. 3097. Civ. CJ
Lenders Nanm
Lender's Address
I certify, that I have rem this application as sum that the above informadun is
comet. I agree to comply with all city and county ordinances and state laws mlmng to
building construction. and hereby °umorim MPrusentadvts of Nis city to enter upon the
purymea
shove-msnudgro propertysit (an inspectioneexpenses
(We) agree ed ave, indemnify and keep harmless the City of Cupertino against
liabilities, judgment, emu and expenses which they in any way accrue ageing aid City
I. consequence of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOJLINT
SOU E CATIONS.
Issued by: Dale .
'e -roofs
Signidure Of Applicand/Cmdanortor Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will me applicant or future building occupant stem or handle hazardous material
az defined by the Cupcnino Mu0"1 1 Code, tltapter 9.12, and the Health and Safny
Code, Section 25532(.)?
❑Yes I
All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or future building Occupant tic a or devices which
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If a roof is installed without first obtainingan inspection, I agree to remove
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.mit us air contaminant ss defined by the Bay Area Air Qualify Management
a Air Qu
all new materials for inspection.
District,
Dixuin7
❑Yes
O&Safad M1enrordommaterials5533 admcnt under Chapmr6.95ofthu Califon.
Adis Hc,imhSafclyhavee, unser .23533 and]553a.I undcrsuM tltuifdc Wilding
d thin si
yesa currently etc a tenent� responm notary nI.
fuwhkh
retire most Wmet riwruissuanc aC BGamerQ`
f
S' atureofA Applicant Date
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All roof coverings to be Class "B" or better
Owner or aummireda ens 7 p,te