04080013 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 1CONaTRACTOR INFORMMATIO�N
BUILDING ADDRESS: CENTEX HOMES PERMIT NO 04080013
III-10 CTP. LOT A-
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0 0 0
LO,
p LICENSED CONTRACTOR'S DECLARATION
m❑ I herbyaffirm Nat 1 un licoucd under provision of Chapter 9(commencing Job Description
iW
with Section 7")of Division Sof the Business and Professor.Code,and my license is
n<a. in full tore and affect.
;'q_ U.M.Class Ue.0 REVISION--DEFERRED TRUSS
43:o Date G.M.CC'SDErLARATION NO NEW PERMIT ISSUED/ ORIG. #04030066
�'` ARCHITECT'S
1 mbcrsund my plans shall M used as public meads
DaU
u.G
Licensed Profcuionsl
OWNER-BUILDER DECLARATION C
f 1 hemhy affirm that 11. exempt from the fcashmas Co License taw for she C�`
Do followingmason emits 7IDL4 Businessand ve dcru.Code:Any city or county
which ro9uiru a permit to co=tta alas improve,demolish,or mpoir any mutter
Pathe incensed e.alsu Ito the tMvision of factum Pernissoice s Lawj utemem
(commosingwiispurstion1 tete of Divisionfine Co usiner indPoleowsCode)r9 Sq.F[.Floor Area ValuatioB 11C)
$ (cammesci tem wish Semioern and of Division 3 of the oged css end Professions ladon of 4
that k u eaemp(therefrom and the buffs for the dlcgcd cmmption.Any violation of
Semon 7031.5 by my applicant for a permit mbjecu the applicant to a civil penally of APN Number OccupancyT
tat mom man fire hundred dolts(53 L YPe
❑I.uawnu o(thepropeny,mmy cmploycu wire waguushcirxlc comperwuon, 36619076 . 00
will due use work and meatcam u not intended moQemd formic(Sec.7004,Buimess
and Profusions Code:The Commcar's Liaise Law docs not apply in an owner of Required Inspections
proper who builds or im proves utereon,a nd who does such work h imsel f or through his
own employes,provided that such improvements;art not intended moRmed for sale.If.
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did nos build or improse fee Popham of
sale.).
❑1.u owner of on,proper,am uclusivcly contracting with licensed ronwmors to
construct the project(Sec.7001,Businew and Professions Code:)The Contractor's Li.
tante law does not apply th an owner of property who builds or improve demon.and
ontcu for such projecu with a contracthr(s)licensed pursuant to don Contractors
nx law.
surron.ropiumboSec. ,Bh PCfarthishmmm
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under Penalty of perjury one of the following declarations:
ars and will maintain a Carolina:of Consent to self-instar for Worker's Cooper.a ran,u provided for by Section 3700 of the labor Code.for the performance of the
wart for which this pernit is issued.
❑1 have and will mpr4ill orke C penis n Insurance,u required by Section
3700ofthe labor pc rem ee of work fwwhich 1pjs Ti(is issued.
My Wm ers Com nam! as a oil,n r
Ca li o.:
CERTIFICATE OF EKEM FROM WORKERS'
COMPENSATION INSURANCE
(This section road nm IN completed!ilk permit Is forme hundred dollars(51(10)
or loss.)
I certify that in the performance of the work for which this Permit is issued,I shall not
employ any Person in any manner x as to become subject o the Workmi Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate or Emmption.you almoW
become subject a the Worker's Compensation provisions of the Labor Code,you must
.,O forthwith comply will much previsin=are dies Permit shall IN dimmed revoked.
Z Vy CONSTRUCTION LENDING AGENCY
[-� I hereby Num that them issconssrucsinn imlI gagemy for the perfomomme of
a > the work fur whim this permit is issma(See 3097.Civ.C.)
CQ Lm&,'s Name
=Z Iendres Address
U C I early that I have mad this application and sur that ON above information u
IL Hcoma 1 agree th comply with sal city and counet
nty ordiro s and sex a
laws relating
C)Ubuilding construction,and hereby auNonmmprexnutivev of this city to enter upon the
r W above-mcnuoned proper for inspection which may
►y (We)agree le save,uncannily and keep harmless the City of Concur.against
Vy liebiliues,Judgmenv,c=uand expenses whim may in any way eccroc against said City
U z in co.equenc of g=ong Of this permit. Issued by: Date
'-'
All LIC RNA DS AND WILL COMPLY WI qLL ON-POINT
SOU RC RE a'(
nature of ApplimnuCoruaclur Done Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will thp applicant m future building occupant store or handle ha minus material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(1)? All roofs shall be inspected prior to an roofing material being❑Yes P P Y g ginstalled.
Will the a licam or fuwr uiWin oar ant rex equipment If a roof is installed without first obtainingan inspection,I agree to remove
np g v 4 Pm1m or dcvic=which P
hanWnu air a..Mir
nm Omantya�s dcGncd by tM Bay Arta Air Quality Management all new materials for inspection.
svictT
❑Yes ❑(yJ r
I have mad the ha adms,�{mp,a�marialsmyuiremcnu under Chapter6.95 of the Calilo>
ria Hcalthde5 C, IhiSM.n533 md
yre,on553G.I IndcruvWthazifth building
Jo.trot cu nd t it u sea responsibility c ley th l the
myuimmcu ansrirraiamraneerr.RniOeaarf Signature of Applicant Date
DW or audhowzd agent D,a All roof coverings to be Class B"or better