04080125CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
CENTEX HOMES
PERMIT NO.
04080125
OWNER'S NAME:
PERMIT ISSUE DATE
ONE:
SANITARY OL0
ARCHITECDENGINEER:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
FF 1 hemby affirm that I am lira sed under pBrvis ons of Chapin 9 (commencing
Job Description
fs wkm Section MM)) of Division 3 oft(nuainms ro@ssiom Code. and my license is
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in Ili fora a fisc,
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REVISION --PORCH DETAILS (PLAN 4)
wts� S Convutor .�—
A CHTTELTS DECLARATt f
NO NEW PERMIT ISSUED/ ORIG. #04030066
1 understand my plana shall be used As public records
I,ccmc0 Pmfessronal
DECLARATION
OWNER-BUILDERoexempt
I hereby .Rr 1 exempt from Ne Law for the
0 on L lmodnctorS e: My city
O Which
following peecdun 703 Consumer,
r,siness hm,tomdme, de rum Croke: Mycity car county
which mquireM a permit to cnmwcL elks impmn, demolish, or repair any structure
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to poor as its issuance. also requires the applicant for such Permit o Ale a signed statement
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that a Is licensed pursuem to the pmvisiom of the Cemruuri liana law (Chepttt9
Sq. Ft. Floor Area
Va nation
$ modurcnring with Section 70D0)nf Division J of the Business and Prefmsinm Code)or
Nat he Is hawthorn
11 Cj
ea or pr' and the basis for to alleged exemption. Any Violation of
Section 7031.1 by airy applicant for a Permit subjects the Applicant o a Civil penalty ofDGQaane
APN Number
not mom than AK hundred dollars (S").
Occupancy Type
pL"OwnerafthePmPsny,mmyemployees with whims a their =to eompensalmn.
36619076.00
willdo the work, and the mon.m is not intended.a.flered farsals (Sec. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
Required Inspections '
propenywho builds orkmpho m Iherron, andwho doessuch work himea for through his
awn employes, provided that uch impronmenv em not intended oroffemd forsale. If.
however, to building or ormanmenl is sold within one year of completion, One owner -
builder will hoe the burden of proving Nat he did net Wild or impmn for purpore of
.).
k1, as owner of Me property. auclusively contracting with Itommad convectors to
retract to Salim (Sec. 7044.'nosiness end Prefcuit m Code:) The Convector's Li.
cause law dose not apply to an owner of property who builds or Improves thereon, and
who contracts for such pmjeeu with a conwcim(t) licensed pursuant to the c.mommes
License law.
❑ %�� B k P C for this mann
�A�Ikl l OMPENSATIONDECI.A AT N
I hereby alTr under penalty of perjury are of on following declarations:
C1 1 ban and will maintain eCertifiate of Consent to self-intim for Workers Compcm
smkon, u provided for by Section 3700 of Ne Labor Code. for the performance of Me
weak for which this permit is roved.
❑ 1 ban and will maintain Worker's Compenratlon Insurance, As required by Sccdon
3700 of the labor Code, for the Perforant, Of the work for which Nis Permit is issued
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My Worker's Compensation hummuce carrier and Policy number am:
Cartier. Polity No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
section used not be completed if use peril is for one hundred dollars ($ trail
or loss.)(This
1 unify Nat in the Perforans of Me work for which this permit u issued, l shall not
'
employ any person in any manncrsn u to Wwoon mdjael to the Workers Compenudd.
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making this Cenificsts of Exemption, you should
become subject 10 Ne Workers Compenution pmvisiom of the Labor Code, you most
forthwith comply with such Pawl ore m Nis permit Mall be domed masked.
CONSTRUCTION LENDING AGENCY
I hereby shirt that dart is • Conswction lending gency for be performance of
to work for which this peril is issued (Scc. 3097, Civ, C.)
Lemer'M Name
Iendees Add.
1 certify that l have mad this application and stats that the above information is
correct. I agree to comply with All city and county ordinances and Mum laws heating a
building Construction, and hereby Aumorim rapresenediam of his city to enter upon me
shovetmentioned property for Inspection purposes.
(We) Agree to sen, indemnify end keep htrless the City of Cupertino sg.inst
liabilities 1 'testa and A.M. whim may in any way same against said City
or'On
in conseyoe a t c8raming Cf mica peril.
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APPLIC U ERZDD WILL COMPLY WITH ALL NpR-POINT
SOUR EGUJL
Issued by: Date _
Re -roofs
st «erAppl�uni � Data
HAZARDOUS MATERIALS DISCLOSUREType
of Roof
Will dm applicant or future building occuputstom m aMle hmmdom matsual
u defined by me Cupertino Municipal COCA, ChMmr 9.12, and the Health and Safety
Code. Section 25532(.)7
E] Y. XN.
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building arupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit harardem air contaminants As dcfincd by the Bay Ams Air Quality Management
Disukc,7
all new materials for inspection.
❑YesNu
T hen mai me Want mrsmemoalsmquhe u under Chants(6.95efthe Calif.,
Oka Health At Safety C 305,2
race 33 2537 understand that if be building
dma no rally ane a at it oy nab y to notify the necupanl of the
requlmm vat hm et pd to eor enifie.moracupanry.
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Signature of Applicant Date
All roof coverings to be Class "R" nr kottn. '
Owner or..th.O,;mdagenl no,