05030089 CITY OF CUPERTINO "4'171,»:3 a'4aan§ A " 7?
BUILDING DIVISION PERMIT CON TRAQTQRAN'F0RMATI0M
Bu1LDlNcnppRFss: TAYLOR WOODROW HOMES peRMITNO.05030089
1115!Rn PARK 11PTUM TM A44
OWNER'S NAME: PERMIT ISSUE DATE
TAYLOR O
E: SANITARY NO, CONTROL NO.
925) 365-3100
ARCHIIECnENGINEER: BUILDING PERMITINFO
BLDGELECT PLUMB MECH
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Ano LICENSED CONTRACTOR'S DECLARATION Job Description
i� I Wreby affirm slut 1 am licensed under provisions of Chapter 9(commencing
wish Sucmn 71K10)ofDivltloA of Nc Besmessand Prof Ions Cadc,AM myliccnnis
R in"'to. t. �Jpcj(� NEW CONDO. (17421 -LIV. SPACE)
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ARCHTIELTS DECLARA ION D-44GE 515 '
tun nim IaneslWlboumdss
a f nal
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OWNEm tee DER DECLARATION
E a s I
he rehy. I dim 11. .Bump(fromo He Conus urs License law for the
Ea p o allowing moron.(Section 7(171.3.Baines.aM Professions Code:My<ilY ar county
5$ which requires a permit m consumer,altar.W prove,demolish,or mpair any suueture
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poor it)its issuance.Alm requires Neapplieast forsuch permit to fie Asigned mwmcnl
F C
that he is licensed Pureammlheprovisions oftWConmcmfsLicense Law(Chapter 9 Sq.Ft. Floor Area Valuation
$ (Commencing with section 70D0)of Division 3 of dm Busiacammd professions Code)or $217333
9 that he is exempt Amerman and the basis for the alleged exemption.My violN,on of
Section 70315 by any appllcml for a permit subjects the applicant a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollars(5300).
0 Las owner of the property.or my employees with wages As Nair mle compensation,
will do the work,and the sumctum is hot monied walleyed forsam(Sec.70th.Business Required Inspections
and Professions Code:The Comm rmes Lianse Law does not apply m An owner of q P
property who buildsorimproves Hereon.andwho doessuch work himalror Waugh his
own employees,provided that such improvenen0 tie not Amended molfered ratable.U,
however,Ne building or improvement Is sold within oro year of compledon,He owner.
builder will have the burden of proving that ha did ret Wild or Improve fur p sopa a of
tile.).
0 1,As Owner of the property,atm emlusively coouning with licensed canuecura m
consumer the project(See.7044,Business and Profession,Cade:)The Cmtrmturs Li-
ave law dean mol apply seam owner of progeny who Wlms or imbnves At...and,
who contracts for such p.jeeu witha mmummrM)licensed purewnt m the CarAmerofa
Lice nm law.
❑1 erre exempt under Sec. .B A P C for His moon
Cm., Dm
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,Can of the following dcelateliont
0 I hew and will mninsin aCertlOcvteof Consent m self-insum luAWork A'sCompen-
abtion,as provided for by Section 37M of Ne Labor Code.for tie Performance of No
work for which this permit Is issued.
0 I have and will maintain Workees Compensation Insuruse,a required by Section
3700 of the labor Code.far de perrormatee of Ne work,for which this permit is Issued.
My Wm mace,s C11om�p11emNm Insure.anis end policy number am:
Carrier. �1'r�� C 6ti7 Policy No.: n
CERTIFICATE OF E3CEMFnOhl n10M WORKERS'
COMPENSATION INSURANCE
Crhissectim sicced matarcompleted if t e permit is for one hundred dollm(5100)
or lest)
I artifY Net In de performance or the work for which this permit is issued.I Nall nm
employ any person in any manner an As m become subject in tie Worlee s'Compcm odon
Laws of California Date
Applicant
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you Amid
become subject 0 the Worker's Compensation provisions of An Labor Code,you must
.7z forthwith comply with such provisions or this permit shall W deemed revoked.
,z„O CONSTRUCTION LENDING AGENCY
(—c I hereby alRrm that there ire construction lending Agency for No Performance of
C?•�
An work for which this permit is issued(Sec.3097.Civ.Cd
GQ Lenders Name _ -
w7 Z Lender's Address
U0 I amity Nat I have reed this application and rete that An above information is
1,- co rcut.I gree to comply MN all city and aunty ordinances and sus laws reining m
0 building construction,and herby Authorise representatives of this city menet uPon the
III above-mentioned property for Inspection purposes.
n. (We)agree be nor,indemnify and kap harmless die City of CupcNna Against
L4) liabilities,judgmemA.eau and espmses which may in my way scrum Against saidCity
U,i; in con ce a'Nc irantm of this permit.
.. A DERSTANOS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REA NS,
Re-roofs
s' etureo pliam/Conmetar I D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
III the applicant or future building Occupant aterc or handl(harudow material
As de0ed by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 25332(a)7 All roofs shall be inspected prior to any roofing material being installed.
0 Yes
Will the applicant or future Wilid aaupanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hoodoos alrcanuminsnu u do tl by the Bay Anna Air Quality Management all new materials for inspection.
Dimie?
0 Yes
ase read deh suadmt mmruis regsOn nems under Chapter 6,95 of He CAIifor•
myCodc,Sc9Oss 25505.25-533must 25534.1 undcnund Net if to Wilding
Iml c fly have a cannot.Net it is my responsibility m ant,fy tie ace Pmt of de
home h ustbomet poor toissueceAra CcNWamoCccup Signature of Applicant Date
.no, uchodmde cm Dote All roof coverings to be Class nBn or better
c