04030121 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON,TRACT,QR�INk.�„ORMA'TIO�„N -
BUILDINGADDRPSS: CENTEX HOMES PEBMITND04030121
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY RC7 C 01-NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EIPCI' PLUMB MECH
0
Iw, LICENSED CONTRACTOR'S DECLARATION
ofCap
��� I thereby arum that l un Gansr.M ammr provisions nr Chapter 9(commencing � lob Description
with Section 7000)uf Divixim Softh Busine t Cock.and ono is
a imm�roneandrcac SF
L-3 STORY (PLAN 2)
L License oa Lic,p
Dam Convaror NG 1753/GARAGE 477 SQ FT
ARCHITECT'S DECLARMON
W U 1 understand my plans shall be used az public meords
6
C Licensed Professional
3 OWNER-BUILDER DECLARATION
E i y 1 hereby affirm than 11. exempt from the CanuacmYs Any c law for the
E p o which
me moon.(Section]o L5,Business and Proressiorm Code:Any city comm.county
which rtyui sa a permit re uires Em alcor,impmu,h permitu nr repair any ment
that kor to its ccomed e.puna requires do,provisions
ofthent tach pcmi's Ucc,rile a signed(Cummcm aI,H,
< (comma cingwiit pursuant to do,of Division
of the,Business ldccnsclaw(Chaprm9 Sq.Ft. Floor Area V.'V1MGOn286
�F$ (commencing with Section700Mand
ndthe viiio(a tof he cBusincasmtlon.Anyavi Code)or �ZUU
_ Net k u exempt therefrom and We bazis fa the aimgct eumption.Any violation of '
Scedon 7031.5 by any applicant for a permit subjects the applicant to a civil penally of APN Number Occupancy Type
.or roam men rive handmd dmlam($500). P Y YP
❑I.mownuofrhepmpmy,ormycmploycuwimwagoaaztheirmiccompenssdon, 36619076 . 00
will do due work.and theme cturt is notintaMed or offered rursam(Sec.]Ola,Business
and Profcsuons Cade:The Contractor's Liame Law does not apply to an owner of Required Inspections
propmywho Wikis orimpmvra thereon,endwhodoessuch work himselfar duough his
own employees,provided that such improvements are ne year fc m offered for sam.own If.
builder.me building or improvementpowinu salt within one year or improv for Ne owned
boater will have the Widen of proving that k did not Wim or improve for purpose of jt
sale.). L
❑1.as owner of the pmpcny,am exclusively contracting with Iieansed amracmn to
construct rhe project(Sec.704E Business and Professions Cade:)The Conuaccum's U. APR cense law docs oar apply to m oilier of,ropeny who Wildsm,i nion.ft. and APR,
who mmmcts for such projects with a conuaccor(s)licensed pursuant to the Coomaxwes aSOD�
License law. ItIllo, S , !
❑I am exempt under See B k P C for this matron F�■/�//. ��
Owner Date �j y
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following tlilantions: CRy
I ham and will maintain.CeniEa¢of Consent to selr-insure for Wo lines Compen.
notion,as provided for by Section 3700 of the Labor Code.for One performance of rk
work for which this Permit is issued.
❑1 ham and will maintain Worker's Compensation Iruurana,as required by Section
3700 of the labor Cade,for to performance ardor work for which this permit is issued.
My Wo— amprocurator mace ca and Policy r upt�r art: �i�
Cartier. Policy No.:
C IRCATE OF-y MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not kcomplcted lithe Permit is foram,hundred dollars(SIM)
or let.)
I ccnifv mat in the performance of the work fm which this permit is issad.I shall not
mnpmy any person in any manner an as to become subject to me Workeri Compeneadon
Laws of C.Iifomia.Date
Applicam
NOTICE TO APPLICANT:If,after making this Cenifcam of Exemption,you shuum
become subject On f Worker's Compensation provisions of the Utar Code,you most
.J z forthwith comply with such provisions or this permit shall k deemed rooked.
Z O CONSTRUCTION LENDING AGENCY
Fw IW-bY-M-that there is a cmimucunn heading sidacy for the perfurmana of
Edi.moi the work for which oris permit is issued(Sec.3097,Civ.C.)
Wa Undoes Namc
z Leadaes Address
U Q 1 ttnify that 1 have road this application and sum that the above information is
B.E-' conccL I agree to comply with all city and county ordinances and sum laws¢lacing to
0UWilding construction,and hereby authorise mpresematims or this city to enter upon the
W 'hove-mentioned property for inspection purlwsea
FULL (We)agrees.sans,indemnify and hip harmless w City Of Cupertino against
ret liebiliu(We)gmenu,costs andunity and lmhmeyinas the Caccrueuertino at City
Uz in consequence of the granting of ibis permit.
"
APP LI NT UNDERSTANDS AND WILL COMPIX WITH ALL NOy.POIM' sued by: Date
E NS.
llJ1JIYY Re-roofs
Signuure of Appli onwnor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will drt applicant or future building Occupant store or hanJlc hmardous material
as derined by tbe Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Sccuon 25532O? All roofs shall be inspected prior to an roofing material beim
❑Yes X .
P P Y g g installed.
Will the applicant or future building accupanc use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air amamimmut as donned by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes l3
1 ham real the hvaidnus mamdals mquimmcnts under CTapmr6.95 of the ralifnr-
does e&Sallyy Cade,Seeumu -1iti 2myoccd]SSJa.l to now,
Wilding '/
tan not cunendy have a mnank 0-1 it is my rcxpomihility m nouty the aeupanr al the V
re /
whachrounbromput9gtoust
/rax m of occupancy.,/ T
.G/i/tom !ugi nature of Applicdnt Date
mer ar samariaedage �� Dam All roof coverings to be Class"B"or better