04030124 CITY OFCUPERTINO
BUILDING DIVISION PERMIT Co, TRACTORA W1 tRMATIOINs
SUUD@4G ADDRESS: CENTEX HOMES PERMIT N464030124
NER'S NAME: PERMIT ISSUE DATE
ONE: SANRARY No. CONTROL NO.
ARCHRF.CTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
1 hereby.(firm that 1 am litmacd under provision o(Chapmr 9(commencing Job Description
inIsh Scedon70s0af ivsuon30fWBusineaand Pm(cWom Co ,andmylieuucis
full feam ane
'z uoen>--�uc.. SFDWL-3 STORY (PLAN 2)
Fg1- ons can LIVING 1753/GARAGE 477 SQ FT
0 ARCHITECTS DECLARATION
I understand my plans shall bo deed as public records
Licensed Prefcsatonal
0
OWNERER DECLARATION
bunchy.(firm that I esemp exempt(mm u
the Canumff LicenseLicenseLaw for the
O0 an
following reason.(Satire 703L5,
consumer.
Business and ".de un Code:My city mcounty
$
which requires npermit re cnns;the tlue impmve.deermitt orerepair anyswmuro
F S° that to s l issuance,also nt to the the applicant the Con permitso Law etaumcm
that heencing licensed pursuant 7 the pmviaions ofision3 ftheB since,LicenseProfession,
(Chapterodc)or Sq.Ft. Floor Area � IPb4P286
that he
umirems ndth(DiWim3 of the cited entandns.Myona Code)of
B that he s exempt thmefmm and W buss(ea thu Waged exempdm.MY Nosdon of
Section 7031.3 by a ry applicant for a peamlt subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than me hundred delves($5110). 36619076 . 00
❑1,u awmr of the pmpeny,m my employeea wish wage u their sole compenndon,
will do the work.md shemucwm is nof3nsnded manemd fonale(Sm.70M,Eastman Required Inspections
and Professions Cade:The Contractors Lineam e Law danot apply to e an owner of q p
ppeny who Wilds orimprmwn thereon,atedwhodoessuch weak himselfar Waugh his
oweemployeu,provided that such Improvements are not lnteMnd manstW Waste.U. ref\
bowevee thebudingarimPmvementhsaldwiinoyea of far
the owmn tt.i.� i _ at
Wilder MU have the Wrdan of proving Wt he did nott Wild or improve(ea puryom of
❑1.as Owner of the property.am exclusively contracting wish licensed conlrawn to ��� ?m
contract the pmjen(See.7044.Business and Professions Code:)The ContracmYs Li-
care law dma not apply to an owner of property who Wilds or improve W recon,and
who mnuans for such prejecs wish a manactor(s)licensed purswnt to An,CmuanoYs'
LicenseLaw,
❑Lem aemDt under Sm. .BkPCfor this won LA� 'j ,t t) 4i
nor Das
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjtny,am of the following dmlatmom:
❑T have and will maintains Cim fins ofCanunt to scif-iuurefm Workses Compere
salon,u provided for by Section 3700 of the Labor Code,far she performance of the
war or which this permit is issued.
I have and will maintain Workers Compensation Insurance.n required by Section
3 00 of she Labea Code,for she performmce aides weak for which this permit Is Wood.
My We . mapcaadan command Polirynumbcrsm: '^
Cartier. Polley No.: G�.3 1�
CERTIFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(rhsaecthon reed not boemnplemd lithe permit is foram hundred dollar(SIOW)
or Wal
1 unify that in ted Performance of arc work fm which Nis pvmit 41umd,1 shill na
employ any person in any manner an u to become subject to W Workers'Compenadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.afar making this Ccniftnte of Exemption,you should
became subject in thc Waftes Compcuadon pmvision of da Labor Cod..you m re
0 O forthwith comply wish such provisions or this permit dull bo doomed remkrA.
z CONSTRUCTION LENDINGAGENCY
l• 1 hereby affirm that there its construction lending agency for the performance or
R'i ^✓ the wart for which this permit is issued(Sec.3097,Co.C.) .
W�Q lender's Name
z TaMes Addw
U0 1 certify that T have mad this application and etas that the above Infmmatim is
L4 E correct.I gree w comply with all city and county crammer,and sus laws misting to
0 building convection,and hemby mthorircrepresentatives of this city to enter upon the
t17 SL •hove-mentioned property for Inspection purposes.(We)aitm to ave,indemnify ad keep harm
mu the City of Cupertino against
i..acn Oabilida,judgmcns.cosesAndexpc"•-,which mayln Anyway acme against said City
V^" consequence
ICANT UNDERSTANDS At
s puraft.
APPLICANT AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
N
0 Re-roofs
ignuurc of Appli V ondacmr Das
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will th.appliant or future Wildini aecupant armeahaMlc has fon unwind
As defend by the Cupetdno Municipal Cade.Chapter 9.11,and the Healsh and Safety '
edc.Secdan 35532(47 All roofs shall be inspected prior to any roofing material being installed.
❑Ya o
Will the applicant or future building occupant tae equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmh havurdous air comuminans As defined by she Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes
I have mud W hamdms mammals requirements under Chapter 6.95 of W Califon
nia Health k Safety Cade,Sminus 25505,25533 and 15334.1 understand that if the Wilding j
docs ret,u.bt Iy bac a unAnt,set It is my res Illybnotify the Occupant of the
re h yny%At wind ar cnincamar Y. U Signature of Applicant Date
Owner or authodoed ADA Dow All roof coverings to be Class"B"or better