05030077 CITY OF CUPERTINO
BUILDING DIVISION PERMIT 7,C®NTRACTOR,�NFUI2MAT01�1
BUILDING ADDRESS: TAYLOR WOODROW HOMES PERMrr No'05030077
OWNER'S NAME: PERMIT ISSUE DATE
E; SANTTARY NO. CONTROL N0.
(925) 365-3100
ARCHI'IECT(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�06 LICENSED CONTRACTOR'S DECLARATION Job Description
rd li 1 hemby affirm Nat I w licensed under provisions of Chapter 9(commend^{
with
Section
aMercecf�D.ivision 3 of then Budmem no Pmfeasiar,Code,and my license Or
;�: Lis Lk. NEW CONDO 1691 SQ FT LIVING
3 oto c^^ ^r 02 SQ. FT. GARAGE
Aacx sDEcuR to
1. M. Y 12Y soul a Tees _
;ILILCnC resiskeal
WNER-BUILDER DECLARATION
I Mmby aBirm that I am comp,from the Contactors License Law for the
O fallowing mason.(Section 703 1.5,Business and Profeuiuns Cade:My city or county
$ which mqulraa a panni,to Construcct,army,borrow.demolW,or repair any struaum
prior to its issuance,Alan,acquires the applicsn,for such Permit to file a sigw.d statement
< Own Wislicensed pursuant mdo,pmvisauofdmConuacmrsLicense Uw(Chapter 9 Sq.Ft.Floor Area Val$41i)fi030
$ (conmendng with Sutton 7000)of Division 3 of the Business and Profession Cook)Or
— Nn he Is exempt thetefrom and on,Buis for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant o a civil penalty of APN Number Occupancy Type
nor mart than five hundred dollen($500).
❑I.umwofthepmpeny,wmymmpioycowithwguuftkmleeompenudon, 36940017 . 00
w0ldothewatk.mdthenmaumismii.=kdooRcacdfwsale(Sec.7044,Bualaa•• Required Inspections
and Professions Cade: h Lena The Conuactalaw does roet apply to an owner of q P
property,who builds ver impmvu thereon.and who does such watt intention through his
own employees.provided that such improvements am not Intended waReed for sake_If,
however.the building or improvement is sold within ore you of completion.the owner•
builder will have the burden of proving that he did net build w Improve for purpose of
ala.).
❑1.as owner of the property,am exclusively contracting wit licensed contractors to
Conswct the project(Sec.7044.Business and Professions Code:)The Contactors Li.
cense Law it=rot apply to an now of property who builds or improves Lemon.and,
who contracts foo such projects with a eamncter(s)licensed purausm to the Contractors
License Law.
❑l are exempt under See B h P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
110 1 hemby aM m under penally of perjury ane of Lha folb ing dedmdons:
❑1 ham oM will maintain a CeNfiestaaf Consent m selfdnsum fu Workers Carepem
sudden,as provided for by Section 37M of the labor Code.for om perforans of the
work for which this Permit is issued.
❑1 have and will maintain Workers Compensation lasurance,as requited by Section
3700 of the Labor Cade.for the performance of the work for which this pent is Issued.
My Workers Compensation Insurance carrier and Policy number am:
Cartier.66L--�-— Polley Na.22L52`2 +�
CERTIFICATE OFF EMPI70N FROM WORKERS'
COMPENSATION INSURANCE
(This sw ire Who not hecwnpleed if0e permit IsformehundmA dollars(5100)
Or PSL)
1 cerdfv that in the performance of the work for which this permit 4 issued,I shall no
employ any period in any manner an as to become subject in[he Workers'Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this CcAOcae of Eumption,you Mould
become subject to oto Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provision,or tis permit shall W darned evoked.
Z CONSTRUCTION LENDING AGENCY
[-r4 1lcreby.M.de,oert isacomuedon lmdi^Sagene,for tie perfunnancoof
CL> the work for which this permit 4lssucA(Sec.3097,CN.C.) '
WM Q Undoes Name ,
7 z Le tier's Addmu
V Q I e mify that 1 have mad this pplication AM see that de shove Infomnlun is
cortex.I agree to comply with all city and county oNl^mces and auk Iaw relating 10
0 building construction.and hereby authobe mpacsentadvea of this city to enter upon ft
aleve-mendonM pmpany for Inspection purposes
(We)agree to save,indcmnlfY and keep aumleu de City of Cupertino against
r0.j34VAII
menu,coau and captious which may in my way name against aid City
(„) of the I=dng of this pCMiL
UNDERST DS N WILL COMPLY WITH ALL NON-POINT Issued by: Date
ULATI /rwZy/
Re-roofs
pplicant r Dam
H RDOUS MATERIALS DISCLOSURE Type of Roof
e applicant or rut=Wilding a xt,shu nom orhaMlc haurdou mAarial
Na defined by the Cupertino Monier ha d
ode.Chapter 9.13.and Health and Safety
Cade,Sectionz553a(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yes u
Will the applicant or future W' ng occupant use equipment or devices which If a roof IS installed without firs[obtaining an inspection,I agree to remove
emit heurdnus air contaminants u fined by the Bay Arca Air Quality Management all new materials for inspection.
District]
❑Ycs
I Ne hasardous matetia4ntuiacmcros under Chaper6.95ofte Califw•
nla "S yCoulo Socil.25505.25533 3377d.l undersuM tuiroe Wilding
d nm cunem haw•vaunt.Net y (Nilly In mofy tie oceupant of tic
mtsw ohm te r .c atearM Signature of Applicant Date
w ramhom<de cm 01) All roof coverings to be Class°Ba or better
2