04030116 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION,.
„s :
DING ADDRESS: CENTEX HOMES PERM"%4030116
NER'S NAME: PERMIT ISSUE DATE
TONE: SANITARY NTR
NO. COOL NO.
ARCHITECr(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i0o LICENSED CONTRACnderpDECLARATION
« 1 hereby affirm that I em licensed under pmvesiarts of Chapter Y mooting Job Description
z with Section 7000)of Division 3 of the Business and Professions Caok,•A�yliccnsc is
in rull forte and of f!/�_
5qz Lice I Lk.a�/ SFDWL-3 STORY (PLAN 2) `loco
n-- Dam Comracmr r. l;
_�_� LIVING 1753/GARAGE 477 SQ FT n
As abill N=i DECLARATION
g understand my plans Mll M u d ss public records
Dc,U
wt; Licensed Professional /
Xin
03 OWNER-BUILDER DECLARATION
<x I hereby affirm that 1 am exempt from the Contractors License Law for the ' �h•iT
D 0 following mason.(Section 703 1.5.Business and Profnsaiom Cade:Any city or county 1
$ which mquio:s a Permit to construct.slier,improve.demolish,or repair any mucture
=i< prior in its issuance.also requires the applicant for Such Permit o Glc a signedmammem q(g�y�
fs0 that he is licensed pursuant to me provisions or the Contractor's Limosc Law(Chapter 9 Sq. Ft. Floor Area 1'--1 V" VL,B6 _
e:h$ (commencing with Section 7000)of Division J of the Business and Pforeuions Code)or - btL -.l
Nat M u exempt mcrtfmm and the bases for the alleged exemption.Any violatian of I - ,) I
Section 7031.5 by any applicant for•Permit subjects Ne applicant a civil pentlty,of -y
not mom than five hundred dollars(s303). APN Number Occupancy Type
I,as owner of the 36619076 . 00
❑ property, my or offered
Heir sole compensation,
will do Prthewon.and theKContranot immnokdoraw it forsale
pply 7D14,Business
and PnywhoW Code:mph sisdor lard Ldwha law does net apply tt an owner is Required Inspections
property who builds or Emphasis thereon,and who does such wok himulf edmrough his
own employees,provided ip such i ,is mid it arenot intended moflemd the matter-
number
the Wilding b r impmwment is sold within one year of c prove for
pu ownes-
builder wiB have the borden of proving Nel M did mot Wild m improve f«puryox of
salt.).
❑1.as owner of the pmpcny.am exclusively convecting with licensed contractors th
construct dm project(Sec.7614.Business and Professions Code:)The Contractors Li.
muse law docs not apply to an owner of property who Wilds or improves Whom,and
who contracts for such projects with a contractor(s)licentid pursuant in the Contractors
License law.
❑I em exempt under Sec. ,B&P C for this mason
0'"have
DamWORKERDECLARS COMPENSATION ATION
1 thereby a(Brm under penalty of perjury one of the following delerommic and will maintain a Certificate of Continuo self-insum for Worker's Compen-
intion,as pmviokd for by Section 3700 of tM labor Code.for me performance of the
or which this Permit is issued.
have and will maintain Workers Compensation Insurance,as required by Section
37 ofdm labor Code for ft performance of the work,f«which Nu permit is issmd.
My Work mpmsadon low nm Gamier and Policy number are:
Career o Polity No.
CERIIFlCATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu semirm..it not M completed if the permit is room hundred WEE.(SIM)
or less)
I certify but in the Performance of the work for which this permit a isamed,I shall not
employ any person in any mannerm as in become subject to the Woncr2'Compensation
La..of California.Dam
Applicant
NOTICE TO APPUCANT.If,after making this Criticism or Exemption,you should
become subject no the Wooer's Compensation provisions of the Labor Code,you most
.Jz ruohwith comply with such provisions or this Permit shall W dcemcd revoked.
zCONSTRUCTION LENDING AGENCY
I-a I hereby affirm that Nem is a cmutmninn lending agency for the performance of
C
be work for which this permit Is is and(Sec.3097,Civ.C.)
W� 0 lanokr's Nuns
z Lender's Address
V Q 1 cenify that I have mad this application arta sum that dee above inrmmnino u -
Uy P correct.I agree to comply wit all city and county ortinances and auto taws relating to
C)V building conswction,and hereby aumorie,representatives of his city 1.mer upon lM
pan
rty
oint
purpo
es
ahm.Zjiioned map oat fort c pemms which may
F 6 (We)agree m save.Indemnify and loop hamdea5 the City of Cupertino against
rn liabilitiesmeno, ents,cosu end expenses which may in any way accrue against said Gip
Vz AcPUCA necofthegrantingof Nis Permit.
APPLICANT UNDERNANDS AND WILL COMPLY WITH ALL NON-POINTATIOIssued by: Date
�O e-roofs
Signa roof ApplicnnvC ter Dam
H ARDOUSMATERIALSDISCLOSURE Type of Roof
Will be applicant or future Wilding occupant store or tuodk hanallom mamrid
as derrned by the C. M.no Municipal Cook,Chapter 9.12.and be Health and Safety
c.Section 255]2(¢)?
❑Yu �U All roofs shall be inspected prior to any roofing material being installed.
\
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or forum building occupam tax equipment or okvims which g p
mit hanamous air conurnmanta ss dcrrned by the Bay Area Air Quality Management all new materials for inspection.
D'talriet7
❑Yes �Nu
1hausmadmeha msm=dalsmquimmenuunder Chapter6.95ofineCalifor-
nie Halm&SafetyCook,
See
25N)5,25533 and 25534.1 unokmand thuirthc building
Jars not cumcndy how a tenant That it u my resppmiM1ili m nouly tM cupant of me
ch ass et pri« unncc ream aracn amy ' nature of Applicant Date
�p
Owner or m(homed ag Dam All roof coverings to be Class"B"or better