04080127 CITY OF CUPERTINO %CONTRA'�CORIFBUILDING DIVISION PENT nK7
'
BUILDING ADDRESS: - CENTEX HOMES PERMIT NO.
04080127
NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY kV 2 OL NO.
ARCHITECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Lop LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am licensed under previsions of Chapter 9(commencing lob Description
x with Section 70011))of Division Sof dm Retire....d Professions Code,and my license is
<a in full force and effect.
^'pz ucen,eCl Lk:p REVISION--PORCH DETAILS
°ate
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G"1BC
ARCNITENO NEW PERMIT ISSUED/ ORIG. #04030081
LTS D LARAT
�S < l understand my pans shall he used a public records NO FEES/ CHARGED TO #04080125
�yU
Q'y Licensed Professional
S OWNER-BUILDER DECLARATION
Comment's
i es I hcrehy affirm Nal 1 L exempt from Nc fesnion,Ca e:A",c Law for the
O C following mason.Permit
1 71131$Business and improve,
de Profession,Code:Any tiny or county
y$ which requires a pewit m rnnurocl.sites improve,demnlixh,or repair any a.n coed -
prior nn its issuance,also requires the applicant forsuch permit no Glc a signed statemem
flatheislicensed pursuonttnthe provisionsoltheConuacmhLicense faw(Chapter9 Sq.Ft.Floor Area Valuation
I-$ (commencing with Section 7003)of Division 3 of the Business and Professions Cadc)or
'� .. Net he u exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pewit subjects fee applicant to a civil penalty of APN Number - Occupancy pe
not mom than five hundred dollen(MOBS.
❑I,as owner ofthe property,or my cmployan with wages ns their sole compensation,
will do the w.&-..d theswnum i.n.tintendedoroffemdfin".m(Sce.70aa,Bnsinrsa 36619076 . 00 Required Inspections
and Professions Code:The Contractors License Law does not apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
awn employe¢,provided than such improvements art not intended oroRered forssle.If,
builder,Heaved o, uimpmvemmnishat heiiinaneyear of completion,Ne owner,
builder will have the burden of proving Net he did not build or improve for purpose of
tele . HCl
u ownero(ct property,am exclusively contracting with:)The
eCeonactors i.
nsa La Ne project(Sec.o an Business and Professions Code)The ms;Contractors rad `✓�
ce a law does not apply je an owner of property who buildsrs improves Comon,and v
'hecontractsLa ts for such projects with aconvecmr(e)lianttal pursuant m Bre Conwclors
License Law.
❑nemexam er Sec. .B&P�rNis mssop
nen Data C
WORKER'S OMPENSATIONDECLARATIO
I hereby af8w under penalty of perjury one of Ne following declarations:
1 haw and will maintain a Certificate of Consent to selltinsum for Worker's Count
ration,as provided for by Section 3700 of dte Labor Code,for the performance of the
work for which this pewit is issued.
❑1 have and will maintain Workers Compensation Intersect,as required by Section
3700 of the labor Com,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.:
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need native completed if the pertain 13 Barren hundred doll°n(5100)
or less)
1 certify But in If.performance of the work far which this pewit is issued,I shall at
employ any person in any manner so as to become subject to Ne Workers Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT.If.after making this Certificate of Excmpnion,you should
became subject to Ne Workers Compensation previsions of the Labor Code,you must
.JO forthwith comply with such provisions at this Fermin shall be deemed revoked.
y CONSTRUCTION LENDING AGENCY
I hammy affirm Nat Nexis a conswcdnt lending agmcy for Ne performance of
ya> the work for which this pewit is issued(Sec.3097,Civ,C.)
A Lender's Name
Z Z Lender's Address
U Q I certify that 1 have Mad this application and amm that Ne show information It
ly F coved 1 agree In comply with all city and county ordinances and sum laws minting to
(J abovcng canawcti ro and forherebyIre authorlm purposes.rettnutives of Nis tiny re enter upon Ne
r G shove-mens) nmdagree
property far inspectionkee
(Wju agme m sew,indemnify and keep hay in an the City of against against
U y incmaiesjualgmenmecosts and expenses which mgin any way actmc against raid City
fJ in cansequence.f Ne grama g r Nis pewit. �{
APPL'CAt"y�UND S�N AND WILL COMPLY WITH ALL NON-POINT Issued by: Date �f�v
SOUR E 0
�� 5�• Re-roofs
Signe Applicam/Conwcmr Die
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safely
otle.Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yin Nu
Will the applicant or future building occupant nen egmpmem ar devices which .If a roof is installed without first obtaining an inspection,I agree to remove
..it comma.air contaminants as defined by me Bay Area Air Quality Management all new materials for inspection.
District
❑Yes XNu
I haw mad the ha ardous materials requirements under Chapter 6.95 of Ne Califon
nix Health alt Safmy Coale,Secdmts 25505,25533 am12553a.1 makomnd metifthe building
does non n y a an at Itis my reapmuibililym ou Ne axupgnt of e
mgaim ensu t as pdormissraneaaracertin GGcq�mer Signature of Applicant Date
Owner or authorised agent D.-. - All roof coverings to be Class"B" or better