04030092 CITY OF CUPERTINO '' " _ '*�"
BUILDING DIVISION PERMIT y CONTRAC-TOR Il,FORMATION:
BUILDING ADDRESS: CENTEX HOMES PERMIT"04030092
OWNER'S NAME: PERMIT ISSUE DATE
CENTEX
,128/20 E: SANRARY NO. CONTROL NO.
92 1 -
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00
LICENSED CONTRACfOR'SDECLARfChap JobDescri tion
�mp I hereby affirm Net I•m 1ksMcd under provisif of Chapter 9(commencing p
<W with Section JtlOU)of Division Sof NC Businns - fc C and. .is
in full forte and
,'q? Liner. Lle.• DWL-3STORY (PLAN 3)
z- Da¢ Cancra r
WING 1809/GARAGE 430 SQ FT
ARCHRECI'S DECLARATION ®w®7
W U 1a
mnd my plans shNbe used l tl public rnrds
For •
y G
Licensed Professional
OWNER-BUILDER DECLARATION ^
a1 hreaso .(firm on 1 am exempt tram Ne Cormamma'sCod Lica.Law for the AK
O o following moon.(Satian JIDLS.BusiM..and Professions Cade:Any city ser munty ' 40
$� which require a permit w construct,alter,impmve,demolish,or repair say swnure Aa-
F Z< prior tu its issuance also requires the applicant for such permit m file a signed satement
that M is licensed pursuant o de providing;of the Comomr's li¢nsc Law(Charmer 9 Sq.Ft. Floor Area Val
¢�$ (commencing with Section 7")of Division 3 of the Business and Proficadmns Crucial or
ey
that be is e.mpt therefrom and he India for the alleged assumption.Any violation of 0700
Section 7031.5 by ury•pptiunt far a permit subjects the applicat to it civil pmahy or APN Number OC'Cil
not mom than five hundred dollars($500). Cup
❑1,u owiter of Ne pmputy,car my employ.with wages as their sole cumpeari ion, l7q(h'yy
will do thework,and the structure is notion led moncmd(orale(Sec.70/4.Businss
and Professional Code:The Canoacmra License law deaut not apply to an owner of 0 0 Required Inspections
property who Wilda or improves thereon,and who doessucb work himselfor through his
own employ.,provided than such improvements are not intended at entered for sale.If.
however,the Wilding or improvement is said within on year.(completion,the owner.
builder will have the Wrden of proving Nat he did rat Wild or improve for purpose of
ale.).
❑1,as mvmr of the pmfxal,•m exclusively contracting wish licensed conrsema to
canswet the pmjmt(Su.7044,Business and Professions Code:)The Connor's Li-
ceve law d=not apply w an owner or property who Wilds or improves theaon,and
who contracs for such pmjccs with a cantractar(s)licarued punuan to the,Commctoh
License Law.
lame0emptunder Sec ,Bh PCfordtismaon
owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby M.under parity of perjury rete of the following declarations:
1 have and will maintain a Cmifcate of Conant to self-insure for Worker's Compen.
.tion,as provided fm by Section 3700 of the ISWr Code.far the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compeassi Insurance,as required by Section
3700 of Ne labor Code,for she pesforetace of the work for which this Permit is issued.
My Wmkcri jcom !a4on lydana ri and Policy number are:
Came. ` .Policy No.:
CERTIFICATE
4M
EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisscction need not W completed if the Permit is(°roma hundred dollars(5100)
or lust
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any peon in any manner.as to become subject in the Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m the Worker'a Compensation previsions of she Labor Wr Code,you most
.J O forthwith comply with such Imaymos m this Permit be daemon revoked.
z y CONSTRUCTION LENDING AGENCY
(-+ Ihereby affirm that Nem is construction lending agcmy for the performance of
C' the work fur which this permit is issued(Sec.3097,Co.C.)
Qlammes Name
lender's Address
U Q I ecnffy that I have read this application and sate that the above inf amnion is
I1.F^ corms.I agree an comply with all city and county milinaeas and state laws mining as
(],U building construction,and hereby authorize mpre.natives of this city to enter upon Nc
aWve-mentioned property for inspection purposes
-
P. (We)agree in save,indemnify and tear,harmless the City of Cupenino against
TA liabilities;judgments,cossa experts which may in any way•ccom agaimtsaid City
UZ in cosequencc of the grating of this permit.
�-' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT I$ ed by: Dat
SOURC REGULATIONS.
_ Com_ 9�,f o�Re-roofs
J Signarum a(Appli HAZARDOUS MATERIALS DISCLOSURE torUere Type of Roof
Will the applicant or future Wilding occupants atom or handle havardou material
as defined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Code,Section 25532(.)?Yea No All roofs shall be inspected prior to any roofing material being installed.
Will the applicam or fuurc building occupant u.equipment ser Jcvi.which If a roof is installed without first obtaining an inspection,I agree to remove
haviur¢I?�oes air conumimos u defined by the Bay Area Air Quality Management all new materials for inspection.
Pi.
❑Yes AN-
I lave mad the harallow materials tequiremcns under Chapter 6.95 of the Califon
ria Rest"SafctySections 255(15.35577 anJ255Nonaa
.lucrsd man if cite Wilding
currently
danot currently
a
y haus a¢nate Nat it is my rtsperobility to wtily Nc eapat.!"he L(i
¢qui¢ enkvwhichmustbem tpri rmi same° aCertificateol p+tpy,+ IS g Lure ofAppl can[ /
�- �,//" /�/�oV Date
own.ser athariR ger, Date All roof coverings to be Class "B"or better