04080015 eNAME:
INO
BUILDINGN PERMIT CONTRACTQRINFORMATIONNe
CENTEX HOMES PERMITNo.04080015
PERMIT ISSUE DATE
SANITARY O 01_N0.
1W (92S) 415-1600
ARCHITECrIENGINEER: BUILDING PERMIT INFO
BLDGEL.ECI' PLUMB MEC"
0 0 0 0
tion LICENSED CONTRACTOR'S DECLARATION JbDecri Iron
YnF 1 hereby affirm that 1 am licensed under provisions oDescription
of Chapter 9(Commencing
SZ�yf with Section 7000)of Division 3 of the Business and Professions Code.and my license is
a iie'remfame amerrecL
License Class l.ic.g FRAM/STEEL/DEFF . SUBMITTALS
L F O Dare Ccu uacmr
n 'Js ARCHITECTS DECLARATION
1e i i uMcrsund my plans shall M used an public memds
Sin
o Licensed Professional - -
Q OWNER-BUILDER DECLARATION
4 a F 1 hcmhy affirm that[ m exempt from the Conhamm's Licene Law for the
o O following ransom,(section 703 1.5,Business and Profession Cade:Any city at county
K$ which requirica permit to consuuck alter,improve,demdLsh.or minor any structure
''toy prior to its issuance.also requires the applicant for such pcmiiito file a signed statement
<
that he is licensed natsuml 1.the provisions of the Canuxnri Liscnc lsw(CTapter9 Sq.Ft. Floor Area Valuation
Xts-$ (commencing with Section 7")of Division 3 of the Business and Profusion Code)or
_
that he is exempt therefrom and the Wants for the alleged exemption.My violation of ca,h
Section 7031.5 by any applicant for a permit subjects the applicant m a civil penalty of 3 WNLrsn�IIVibu0 0 Occupancy T
not mom than five hundred dollars($500).
p y y�
❑L o the wmk f the pmpmy,err m not inti yces m.ffergu as ae(Sec.campewness
will Pr thework ands: he Comisnot intended orowredfor sale(See.to An Business
and Professions u Cade:The Contractor's Lit who law dais not apply lf an owner is Required Inspections
property who builds or impmvuch impr and who Am not in work himrelfm through his
own a however.
the uiprovided improvement
lit is ssmenu in not ear ofcded moRemd theforow.r.
however.the building or improvement is sold within on year of completion.the owned
builder will have the burden of proving Out k did not build w improve for puryase of
1.u owner of the property.am exclusively canuacting with licanud contractors to
wet dm pmj.a(Sec.7044.Business and Profusions Cods:)The Conmmne.Li
eche law does not apply to an owner of property who builds or improves themon.And,
who mnwcs for such pmjecu with a convacta(a)licensed purwant m tk Contractor's
License Law. -P
lamaaem .B&PCfor s on
o at Dam I65
WORKER' MPENSATION DECtI.:.RAT
ION /
I hcmby affirm under pmulty of perjury arc of thelblloFing declarations:
have and will maintain aCcoifieate of Conant loself-inure for Worker's Compno- 1/
ration,as provided for by Section 3700 of the Labor Cale,far the penfmAnimc of the JCC
work for which this ptmril is issued.
❑1 have and will maintain Worker's Compensation Insurma.as required by section
3700of NC labor Code.for rhe performanceof Ne work for which this permit is issued.
My Workers Compcuadon Insurance carrim and Policy number am:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('ITis sectinm need not be completed Kthe pewit is forma hundred dollars($100)
or less.)
1 certify that in the performance of the work for which this permit is issued.l shall not
employ any pecan in any manner an as to become subject to the Workers'Ccarx.don
Laws of California Dau
Applicant
NOTICE TO APPLICANT:V.after making Oris Cenifieam of Exemption,you should
become subject in the Worker's Compensation provision of are labor Code,you mute
.JO forthwith comply with such pravisirm
nm or this peit shall be deemed revoked.
'Z.J.. CONSTRUCTION LENDING AGENCY
[-+ I hereby aRrm that there is a Caribbean.lending age.,fm the puharrane,of
the work for which thio permit is issued(Sec.3097.Civ.C.)
Uj Q Lenders Namc
C Z Lender's Address
U
V Q 1 certify that i have mad this application and sum that the above information rmadun is
t,;,� cows I agme to comply with all city and county ordinances vasclubs
and Cute laws relating to
p t.) building rationed ion.And PmKityhembyauthorinrposes. utiscs of this city mcnter upon the
aMve-mentioned pmpeny for inpeetios purposes.
F9L (Wc)again to ave.indemnify and keep harmless the City of Cupertino against
UZhadnIfliics"Idemems ars and axis"v.which may in any wayaccrueagartit said City
in g mi of is permit. /
SPPLCER L E S ND WILL COMPLY WITH ALL NON 01 Issued by: Dale
SI mare G1 Re-roofs
P 1 H ZA taCtlSAfATERIALS DISCLOSURE ate Type of Roof
Will rhe appiicam or furore building occupant atom or handle hararduus material
As&flood by the Cupertino Municipal Codc,Chapter 9.11.and the Health and Safety
Awk�aqc.S❑ a zss3zla/
'Ca yNa All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I hmaakma ail Common aysys defined by the Bay Area Air Quality Management all new materials for inspection.
u n]
❑Yes
I have real the hasudous materials mquimmenu tookuCMpar 6.95of the Califor-
nia Hcaldt&SafctyCodc,Sccdau 15505,25533 and 15534.1 and ro=d Nat if tM Wilding
dors not currently he a L tha i1tA my responsibility 0 nobly the occypart 9f the
mquimmenB wh must me issaanceafa Ccblmmof scup Signature Of Applicant Date
\
r or Abut Dim All roof coverings to be Class "B"or better
Ow red