04030101 CITY OF CUPERTINO
BUILDING DIVISION PERMIT �CONTRACTORaINFORMATION =,,
DING ADDRESS: CENTEX HOMES """'04030101
NER'S NAME: PERMIT ISSUE DATE
ONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
unae,p r--10 LICENSED CONTRACTOR'S DECLARATION
w 1 hereby affirm met 1 am licensed under provisions of Chapter 9(mmmcncing Job Description
i4 with Sccsion OM)of Divpion 3ofmc 5556 imm�mroeand BusinandarPofde, iyImmicis
jp
SFDWL-3 STORY (PL5)ul
a_o Dam Contraetor LIVING 1992/GARAGE 430 SQ FT � ^ n
ARCHTIECTS DECLARATION
"
WU 1 understand ms s
y planhall M tared as public record
3u. Licenced Professional
G OWNER-BUILDER DECLARATION
<I 1 hcrehy affirm ma,1 am sang,from the Contractors License Law for the
00 following mamn.(Sectiun 7031.5,Business and Professions Cade:My city or county I
$ which requires a Permit to construct.altars improve,demolish.or repair any structure r�
t-iw prior m its issuance.also require the,applicant for such Permit o file a signed sta¢men,
PP C
than ha is licensed pursuant to the provisions of the Contractor's License law(Chapter 9 Sq.Ft.Floor Area ; IVat+sfltiflTF,00�-\5
,y
(commencing wish Section 7")of Division 3 of the Business and Professions Code)or
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that Ire is exempt therefrom and the basis for the alleged exemption.Any violation ofSection 7031.5 by arty applicant roe a permit sublime;the applicam to a civil penalty or APN Number Occas T
not mom mm live hundred dollars(M). Occupancy Type
01,u°wmronheprpnt mmyemploycuwimwageumcirmlcc==ninon, 36619076 . 00
will dome workk,and mestructum is not intended or offered for sale(Sec.7W,Business
and Prorutlmu Code:The,Comuactors Li.Law coca nut apply m an owner of Required Inspections
progeny,who builds or improves memon.and who does such work himulf or through his
own employees,provided that such improvemenU are not intended oroRereA forule.IL
however,We building or improvement is sold within one year of completion,the owner.
builder will have the burdan of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contraction to
construct the pmjcct(Sec.70,4.Business and Protections Code:)Tee Contractors Li-
em se law doe not apply to an owner of property who builds or improve thereon,and
who convects for such pmjccta with a conwcroKs)limned pursuant to the Contractor.
License law.
❑1 am exempt under Sec. ,B&P C for div reason
me Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following accusations:
I has and will maintain a Cenifiate or Cmmunt ro self-insure for Wmkere Comom.
anion,as provided for by Section 3700 of the labor Code,for de performance of de
work for which this permit is issued.
1 have and will maintain Workers Compma mtin Insurance,u required by Section
3 o(,he labor Coda.for mm Performance of me work for which this permit is issued.
My Worker.Compensambn llis/erecta eammu and Policy o max, art: �J��y g(
CO.. -4172 '/ Policy No.:a^ Tiµ fie/ r
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Crhis section need not bec°mple,ed if the permit is routine hundred dollars(SIM)
lir le..)
1 cenify that in the performance of she work for which this Permit is issued.l shall not
employ any person in my manner an as an become subject to mcworkers'Compensadon
Laws of cilifmmia.Dau
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption,you should
become subject to the Worker's Compensation provisions of use law Code,you mum
.J O rod with comply with such provisions or this Permit shall W deemed revoked.
Z ti CONSTRUCTION LENDING AGENCY
Ihauby affirm dual Bert is a construction lending agency for the perfermance or
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the work for which this panni,is issued(Sec.3097,Civ.CJ
A Lender's Name
_ Lcndcrs Address
U C) 1 renify that l have mad this application and!sum 0.son above inromu,ion is
",F comes.I agree to comply wish all city and county ordinances and sue laws rclaing to
C)U building comstruction,soul wrabyauhorine representatives of this city to cnur upon On
yahov-mendonee property,for inspection purpoua
(We)agree,o save,indemnify sod keep bawless the City of Cupertino against
rq liabili,iu.judgmcnu,costs and experts which may in any way same agaimussid City
(JZ inconmqummorthegransiogafthis permit. AL
^;the
T UNDERSTANDS AND WILL COMPLY TH L NON-POINT ISS by; Date
E TI S. !_//
�C- Re-roofs
APplicanVConl DareHAZ, DOUS MATERIALS DISCLOSURE Type of Roof
e appliaritorfuture building aeupmt Woreor"' M hueethius material
y do Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
n zss3z(a)7All roofs shall be inspected prior to any roofing material being installed.
a IIIV°the applicant or future building Occupant tax equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
us air contaminan as fined by the Bay Area Air Quality Management all new materials for inspection.
Ye
1 have mal she hmard°us materials mquiremcnu under Chapter 6.95 of the Calilor-
nuHealth&Safety Code,Seen.35305.25533 and z553,.1 understand that iftM building
dors no,cometly has•tenant,Na,I,u my msPouihili y to nodWD.
gnature of Applicant Date
All roof coverings to be Class "B"or better