04080130 CITY OFCUPERTINO' _ K "^*x
BUILDING DIVISION PERMIT ,CONT i' ,,Tb INVO J
BUILDING ADDRESS: CENTEX HOMES PERMIT NO
R'S NAME: PERMIT ISSUE DAM
116/2
CENTEX HOMESSANITARY 0. CONTROL NO.
InrONE:
ARCHI'IECUENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
uOpLICENSEDCONTRACIOR'SDECLARATION Job Description
s�i p 1 hereby affirm Nat 1 am lianud under provisions of Chapter 9(commencing
t� with Section 70M)of DiWsion 3 of Nc Best..and Pmfcasions Code,andmyliecnxis
n zinfulcciam cttce. REVISION--PORCH DETAILS
nz D�aense Class Contracte _ L
e cH ECTSDECLARATON NO NEW PERMIT ISSUED/ORIG. #04030083
Y 1 undcrsand my plans shall M used as public mends
wQ
Licensed Professional
S OWNR-BUILDER DECLARATION J
1 hereby.('firm that IE.1. cBcmpt from dm Cnnveeols e:Any C Law for(be 4.V.
p O following moon. erten t 7(13 1.5,Business and w.the ore Cade:Any city or county
+$ which rcquims a permit re cnnaw0.epee improv,b permit
er it t or mash any statement F=�
poor it) issuance.alae requires ft applicant for such permiuo file aaigncd smtemcm
iixxG that he is licensed pursuant in the provisions OfdoConvecmriLicense law(Chapter 9 Sq.Ft.Floor Area IUatl
.Cf-$ (commencing with Section 7")at Division 3 of the Business and Professions C.&)or \
r3.. Nat he is ezcmpt memfrom and the basis for the alleged esempttw.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant in a civil penally of APN Number Occupancy Type
not more man five hundred dollars(5500).
❑Laownerof Ne pestruc intended
wimwagesamelr tele compensation,
willdo thework end Nectmclum is not intended oro@red Tousle(Sec.]044,Business
and Professions Code:The Contractor's License Law does not apply to an owner of RegUlred IDSpeCtlOnS
property who buil ds m improves thereon,and who does such work himself or through his
awn employers,provided that such improwmema are not intended mollmd forsale.if,
however,the building or Improvement is sold within one year of mmpleuon,the owner- +
builder will have the burden of preving mat he did not Mild or Winnow for purpose of
u owner of the progeny,am exclusively convecting with licensed contractors n
cs Ne limited(Sec.70.4,Be ftera and Professions Code:)The Contractor's Li-
who contracts w docs not applyje an owner of property tube Milds or improves centro,and
whe wfor such projects with a eonvecmr(O licensed pursuant n Ne Convectole
License law.
❑lan,ezemptu Se ,8ffi PC for this mason
rte Date
WO ER' ENSATION DECLARATIO
1 hereby off., under penal) of perjury one of Ne following ib clmmpmu:
I haw and will maintain a Cerni0cate of Consent M self-insum for Worker's Compen-
mtker,a provided for by Secuon 3700 of the labor Cade.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 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation lnsumnes carrier and Policy number are:
Cartier. Policy Nn;
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not M completed ifthe permit is foronc hundred dollen(SIM)
no teas.)
1 eenify that in Ne performance of the work for which this permit is issued.I shall not
employ any poison in any manner so as to become subject o the Workers'Compenation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Ccnifica a or Exemption,you should
become subject n the Worker's Compensation provisions of the Labor Code,you must
�Q forthwith comply with such previsions or this permit shall M deemed revoked.
z H CONS AUC`DON LENDING AGENCY
F" 1 hereby affirm that Bert is a Convection lending agency Car to performance of
FC 7 the work for which cis permit is issued(Sec.3097.Civ.C.)
QLento's Namc
Z)z Lender's Address
U C) I Certify that 1 haw mad this application and soon that the show information Is
ft. H correct.1 agree m comply with all city and county ordinances and some laws misting to
0U building Convection,and hereby authorise repreaenbtivra of this city to enter upon One
above-mentioned progeny for impecuon purposes
Hy (We)agree to save,indemnify and keep harmless the City of Cupertino against
U IZI z habilities,jud CO..c abs expeaee which may in any way accrue againslaid City ✓ /
in copse ce f a of This ,.it.
APPL ANT D NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date — d ^0
SOU ER S. �G SIl Re-roofs
Signature of AppiicaVConODate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant ser future building e.Chapter
stem or handle Health anmateriel
az defined by IM Cupertino uni u al Code,Gapter 9.12.and the Health and Safety
ad.,seeuan xss3xan
All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
.mit Mvardnus air contaminants az de0ned by the Bay Area Air Quolly Management all new materials for inspection.
District?
C Yce Nu
Ih ad the Mvardous urialsntquiremenb under Chapter6.95 ofthe Califor.
nia Hcal cum
1 C u 25M5,35533am1]5534.Iundersmndlhatifthe building
does n One
son
4 then it is my maporuibility m noddy Ne occupant of the
mquim toes us c(Adore issuance ofa Coni0cate of Qerypaypy. Signature of Applicant Date
t,LO
Owner or mh.m.ed a gent
aDar,"r All roof coverings to be Class"B"or better