04030117 CITY OF CUPERTINO •'�' '- '`�+ e ^" '�'* a "°
BUILDING DIVISION PERMIT CONTRACR INk,'ORIATION h;
auILDINC,ADDRESS: CENTEX HOMES PERMITNL04030117
NM'S NAME: PERMrr ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 I� 0
LOO LICENSED CONTRACTOR'S DECLARATION
�2 u 1 hemby af0,m that 1 am licensed under provisions or Chapter 9(c mmeneing Job D85Ci1ptlOn
iN Sation]q)U of Digsto fWBusiness asJ Profess' s o@.v fjkemeu
full loom i
;q= ev G Lic.g LIVINSFDWLG
3 STORY (PLAN 7) ����®
—o Da cwnvarwr LIVING 1753/GARAGE 477 SQ
ARCHMiCTS DECLARATION
�i c I understand my plans shall he used as public records
3 G t Licensed Professional
S Oat I am exempt
from
DECLARATION
2 1 rechy affirm(Section n I am exempt from iPo Contractor's License Law fou the 200&
❑O followingerm,1703 cont,Business and hofessiov Code:Any city of county L
$ which mquirus a issuance.alsore cores the alter,intprom,dommlh Permits nr repair any structuned tatement
Fib nbatprioWits ensedlw requires the pre of far Contractor's le a
aw(Chtemem
FS Nmheiscingwiit pursuant to the previsions ofWComrxLIcevelsw(Chapter9 Sq.F[. Floor Area
C is dor he is
(commencing Section gond the
Division]or W Business caaxe priond n.Any vi Code)o
`<—
door he u exempt Nuefrom and W bvu for the Jlegcd exemption.Any violation of BUILDNG
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than r.hundred dollars(s500). 36619076 . 00
p y YP
0 I,u Owner of the property,or my employees with wages an their sole compensation,
will do Om work,and the structure u nos intended or oriented run We(Sec.7014,Business
and Professions Cots The Contractor's License Law door not apply w an owns,or Required Inspections
property who builds or improves Wmon,and who does such work himselfor through his
own employees,provided that such improvements art oat intended Or offered for sale.If.
howevo.the building or improvemam is sold within om year of completion,the Owner.
builder will have the Wrden of proving Bram he did net build or improwe for purpose of
sale.),
0 1,as Owner of the property,am exclusively commenting with ImevW contractors to
consumer the,project(Sec.7044,Business and Profession;Code:)The Convector's V
cove law docs not apply w an owner of propeny who builds or Improm thereon,and
who contracts for such projects with a eonrracwr(s)licensed pursuant on W Conwewr's
License Law.
0 lamvempsunder Sew ,B6:PCferthisreason
nor Date
WORKER'S COMPENSATION DECLARATION -
1 hereby affirm under penalty Of Perjury one Of W following declantiov:
1 as and will maintain a Certificate of Consent to self-insum for Worker's Compen-
anion,v provided for by Section 3700 of W Labor Code,for Ne performance Of the
wo for which Nis permit n issued.
»m and will maintain Worker's Compensation Insurance,as required by Section
3]00 of Ne labor Cole,for Ne performance of the work for which this permit is issued,
My Work �Osau�go�lluuunjocecanicrand Policy umber -
Cartier. /m I`^ ' Policy NO �C/J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not b)cmnpleted if the Permit Is foronchundmd dollar($100)
or tests.)
1 cenifr that in the performane)Of Ne work for which this permit is issued,)shall nos
employ any person in any roamer.as W become subject t0 the Wokers'COmponsmom
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certifica o of Exemption,you shorld
become subject to the Worker's Compensation pmvisiom of Ne labor Code,you mum
.J O rorlhwidt comply with such provisions Or this Permit an deemed mOked.
ZN CONSTRUCTION LENDING AGENCY
[—� Ihemhy aD9rm do.Nem is.coretructim lmdinggency for Ne penfurmanceof
!Yi ti
the work for which this permit is issued(Sec.3099,Civ.C.)
A zLender's Nun,
Lend,rl Add.
U Q I certify that 1 have read this applicnim aW sum that Ne above information is
D, F con)cL 1 agree to comply with all city and county Ordinances and mm laws relating to
0 building communion,and hereby aurhorfm rtprtsenutiwu Of Nis city to error upon the
above-mentioned Property fur inspection Purposes.
H 4 (We)agree to save,indemnify and keep harmless the City of Cupertino against
V1 incorompsuceofth,costsand efPcveswhich may in any way accna:against said City
U,Z APPL1 gvnc)Of UNDERSTANDS
ng of this D WILL
^ APPL NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT red by: Date
CATIONS
yy ' a Re-roofs -
gnuurt of Applic HAZARDOUS MATERIALS DISCLOSURE Date Type ype of Roof
Willy applicrattarforumbui ICooccupantstoreor handle Health and
az dC.Section
the 32(a)? o Mes al Code.Chapter 9.13,and the Health and Safny
C.5) y.zss3z(a)] All roofs shall be inspected prior to any roofing material being installed.
❑res
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant or fissure building ottupam use cyuiPmenl or devices which p
mit hazardous air contaminants as defined by Ne Bay Arta Air Quality Mwgement all new materials for inspection.
District?
O Yen
1 have mad the havam ms mawrials requirements under Chapter 6.95 of Ne Califor
nice Hesi"Sal,tyCOd).Sections 25505.25533 and 25530.1 mumme d W if N)Wilding
d nendy haus s mnanL Nes it u my msporuihilit w mufy nor acupans nr dm
tai en ch m etprio issuamcOfa a mmo.focc mcy' S ure Of Applicant Date
Ownerorausnomedas D,IJ All roof coverings to be Class "B"or better
G