05030049 CITY OFCUPERTINO x� vaa
BUILDING DIVISION PERMIT �CONT"6TQR INFORMATION. s.
BUILDING ADDRESS: TAYLOR� WOODROW HOMES ""0'05030049
1119RO PARK GREEN T-N 845
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(925) 365-3100
ARCH]ECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
300 LICENSED CON7RACIOR'S DECLARATION
I hereby af0,m gut 1 are licensed under provisions of Chapter 9(commencing Job Description
i with SaUon 7")of Division 3 of the Business must professions Cods,and my license is
w In full rereaand affect. NEW CONDO. (19381 -LIV. SPACE)
License Claes l.k.g
[[ GARAGE 568 '
' Dam 1.1,.
ARCH SDECLA A o D-45
In Hund y plena I d u Case c
] VI
License recessional if
OWNER- ILDE ECLARATION
ray 1 hereby alarm that 1 am exempt from the Conm.or's License Law for the
`O fallowing won.(Section 7031.5,Bumex and Professions Code:My city or county
which requires a permit m cmeam t,alar.Improve,deme)W,or repo,any Mae.
prior an its issuance.slaw requires the applicant for such pclmit in file asigned statement
-�< Nn he is licensed pursuant In the pmviamu of the Couractorl License Lsw(Chapter 9 Sq. Ft. Floor Area Valuation
zCB (commencing with Section 7000)of Division S of the Business and Professions Code)or $241650
3.- Wt Cutts exempt Nenfran and do bub for the alleged exemption.My violad,on of
Section 7031.5 by any applicant for a pewit subjects the applicant m a civil penalty of APN Number Occupancy Type
not mom than five hundred dollars(M).
❑1,u.wner of tha property,or my employees with vngos u gx'v Cole compensation,
will do the work and Neawcture is not intended proffered for We(Sec.7044,Business
and Professions Cade:The co moor's License Law dose not apply In an owner or Required Inspections
property who Wilds or improves garcon,and who does such work himself car through his
own employees,provided Nat such Impmvementx art not Intended ora@red forsade.If,
however,the Wilding or improvement Is Cold within one year of completion,this owner.
Wilder will haw One burden of proving Wt he did Out build or improve for purpose of
sale.).
❑1,as Owner of the property,am exclusively connecting with licensed contractors to
construct tis pmject(See.7044.Business and Professors Code:)The COmrComr's Li.
cense Law docs not pply In an owner of property who Wilds or improves gemon,and,
who conmcts for such pmjecu with a eonwcmr(G licensed pursuant to the Conaactors
License Law.
0 I an exempt under Sec .B A P C fm this necom
veno, Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decimations:
❑l has and will maintain Canifiesm OfGment mulFlnsum for Worker's COmpe.
uCion,as provided for by Scatter 3700 of the Labor Code,for the perfornencm of the
work for which this Carni,is issud.
❑I haw and will maintain Worker's Compensation Insurance,sa required by Section
3700 of the(Abor Code,for de performance of the wort(at which this permit Is issued.
My Work/er's�Com�pensation Insurance carrier and Policy Currie
am:
Grrier.�ry-V ( Dfr"1 Polity No.: 'h tn� IVbD
CERTIFlPIION FROM WORKERS'
COMPENSATION INSURANCE
(Tbtasecgnn nerd notlwcomplemd tithe pewit laforew hundred dollars($100)
or less)
1 unify gust In the performance of tin:work for which this permit is issued,l shall not
employ any penton In my munerCo u to become subject to tie Worken'Comper.ation
Laws of Califomla.Dam
Applicant
NOTICE TO APPLICANT:If,after making Chis Ccninca a of Exemption,you should
become subject to the Worker's Compensation provision.of Code Lehr Code,you must
.JO foMwith comply with such pmvidens or this pewiuhall Inc deemed revoked.
'Z0 CONSMUCf10N LENDING AGENCY
[r Ihomby afllw mal them is a construction lending agency for the performance of
the work for which this permit is i.ud(Sec.3097,Civ.C.) '
W�Q Lender's Name
z Lender's Addw
U0 I certify that 1 have end this application and state Chad the show Information b
{g. corm I&Smte to comply with all city and county ordinances and abuse laws misting to
O Wilding construction.and hereby authorise reprrxnutives of this city to maer upon the
f>a ahove-mernma property for inspection purposes.
gyr (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.jumenuns ms
N dg ,coand expenses which may In any way seeagalmt Heid City
V 7 I nce of the granting of this permit.
F7 PPLIC UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
URCE ECU ONS.
Re-roofs
SI u fnpplim vac r D
HA2AR U RIALS DISCLOSURE Type of Roof
Will she applicant or f sere building occupw store or handle hasardous material
u defined by the Cupertino Municipal Code.Chepe,9.13,and the Health and Safety
Corm•Sc YOcna 25533(x)7 Yr W/ All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future lding occupant ase equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
..It hoard..ole comm. Hud by the Bay Arta Air Quality Management all new materials for inspection.
Disuid7
❑Yu u
I have read the hvsrWms materials mquiremcnu under Chapter 6.95 ofthe Califor-
n' saf.ycam.smnons 25105;5533 and 25534.1 understand Chat ifthe Wilding
eas not cu ndy haw a unant,that It.4 my responsibility m notify the roup.,a thc
m Creme whk muuussstW 'o Issuanccofaccruncateofoccupan Signature of Applicant Date
7
Ar or authorized agent D All roof coverings to be Class"B"or better
C