04080040 CITY OF CUPERTINO T `��" a� "''°
BUILDING DIVISION PERMIT 'C RAG, bR TNFU tMATIO ,
BUILDING ADDRESS: CENTEX HOMES PERMIT NO.04080040
L OWNER'S NAME: PERMIT ISSUE DATE
E:CE
SANITARY O. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOO LICENSED CONTRACTOR'S DECLARATION
a V I hereby affirm Dthativision
1 am Ranted under and
provisions of Chapin 9(commencingsis Job D¢SCrIp[IOn
<^� with Section and afecDivision Sof the Buainessand Professions Code,and my license is
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infullat Lie R CONSTRUCTION STAGING PLAN
MDateCoalmnnr
qFQ ARCHITECTS DECLARATION
�i 2 I underrunei my plaus.hall he used u public retards
D�u
irLL� Licensed Professional
OWNER-BUILDER DECLARATION
j�Y I hereby aRrre Nal 1 am exempt from the Cantomwes License Law for the
O O following reason.(Section 703 1.5,Business and Professions Code:Any city or county
k$fl! which requires a permit to construct,eller,improve,demolish,or repair any structure
N2'o prior In its issuance.also requires the applicant for such Permit rile a signed statement
pp < that he is licensed pursuant in the provisions or the ConnotessLicense Law(Chapter 9 Sq.Ft.Floor Area Valuation
k a (commencing with Section 7")of Division 3 of the Business and Professions Code)or
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that he is.tempt therefrom and the basis for Ne alleged exemption.Any violation of slis
Section 7031.5 by any applicant for a Permit subjecu the appiinalto a civil penalty of APN Number Occupancy 71y
not more Nan five hundred dollars($500). - P y '7 Pe
D I.as owner of the property,ormy employees with wages u their sole commmadon,
will do Nework and Ihestreacwre isnot intended oroffercd formic(Sec.7041,Business
and Professions Cade:The Comescmra Liana Law does not apply to an owner of epS*Inspections
property who buildsorimproves thereon.andwhadoessuchworkhimselfor through his OS, t�--
own employees provided rhatsuch improvements are not intended oraRered forsale.If, /t L
however,Or building or improvement is mid within one year of completion,The owner- l..
builder will have the burden of proving that he did not build or impmw:for purpose of
all ).
h as owner of the property,am exclusively contracting with licensed conuaclm,to
stmct the project(Sec.7011,Business and PfafasSloea Code)The Communes U.
n Law does not apply to an owner of property,who builds or improves themon,and
who convects for such projects with a.omen or(t)licensed pursuant In the Convenors
License Law.
❑Ivo eacmp ISe .B&PC''jffm.tb�os.�� .
ne
Owr
O 0 4PENSATION DEC ON
hereby aBirm under Penally of perjury one of the following declautimee
have and will maintain a Crrtificam of curamt m ulf-inure for WorkersCompen-
'tion,as provided for by Section 3700 of the Labor Code,for The Performance of the
work for which this Permit is issued.
D I bast and will maintain Workers Compensation Insurance,m required by Section
7700 of the Labor Cade,for the performance of Ne work for which this pennies issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This seeian nerd not becomphand if rhe pc.I,isfnronc hundred dollars(SIM)
or lust I
I ardfy that in the pnformance of the work for which this permit Is issued.I shall not
employ any person in any manner an a in become object a the Workers'Compensadon
Laws of Califomie.Data
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption.you should
become subject m the Workers Compensation provisions of On labor Code,you most
Q O forthwith comply with such provisions or this Permit shall bd deemed invoked.
,z.i CONSTRUCTION LENDING AGENCY
ser I herebywhaRrmthuthcrc issued(Se.construction0 lending agency for the performance of
rr! ti
be work for which Be.permit it issued(Sec.J09'T,Civ,C.)
W� Q Lender's Name
= z Lender's Add..
U Q I anify that 1 have read this application and sum that Be,above Information is ,
LL correct.I agree to comply with all city and county onlinances and ark lawn relating to
Q V building convection,and hereby authorise mpresenmtivu of this city to enter upon the
W) ahoy-ms,judg d property far iespe omsexpenses
purposes.
gyt (We)agree to save,indemnify and keep harmless the City of Cupertino against
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ofthecraBindof this
esmitch may in anyway ecus.against mid City
U z A consequence of The grunting of this permit.
" APPLICANT ERST DS AND WILL COMPLY WITF�.L NON.POINT Issued by: Date
SO RC GU Z
/LMC. Re-roofs
goal ppb_ CZARDOUS MATERIALS DISCLOSURE Dam
HAType of Roof
Will the applicant or future building occupant stare or handle ha sedous material
CM
derned by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
C 1a,SDNon25532fa)7All roofs shall be inspected prior to any roofing material being installed.
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Will the applicant or future building occupant tau equipment or devise which If a roof is installed without first obtaining an inspection,I agree to remove
I havardous air comer inanr m u defined by the Bay Arca Air cattily Management all new materials for inspection.
strict? wryp
Dyes
I have mad the ho anhoomamrials requirements under Chapter6.95 of the Califor.
ria Ne
IyCodc,Scemons25505,255J3 and 25571.I understand Bandon,holding
does not sat o ten 4 that it is my responsibility m notify the acupent of me
rcgoi ca n hm br at ruiuvaacohCcnificamofOcc9pancy. ` Signaturcof Applicant Date
wner or authorized agent �(� Date All roof coverings to be Class "B"or better