04030104 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT t-UNTRA.C'I`)", NFORIR ATION
BUILDING ADDRESS: CENTEX HOMES PERMIT Nb4030104
LI ? PATMPnW MR
NER'S NAME: FBRMITMSUBDATB -
UNE: SANITARY NO. CONTROL NO.
ARCHMCr/ENGINEER: BUILDING PERMIT INFO
BO ELECT PLUMB MECH
O
+r0o LICENSED CONTRACTOR'S DECLARATION Job Description
(Y 1 hm Thu thereby affvi am liamed under provisions oecrP
of Chapter 9 rommbocin{
with Section 7010)afDiv'sion 7 of the Buslaeu and Profen a de. ylicam 13
in fullfoaend ( ct 1� Lung SFDWL-3 STORY (PLAN 5)
S�? Liccrrc a
Dmte cankecmr LIVING 1992 GARAGE 430 SQ FT
B ARCHI]ECrS DECLARATION
I understand my Plate altaI W used As public=ends
7
C Licensed Professional
OWNER-BUILDER DECLARATION
A y 1 Mem .(Sete thus 1 1. exempt from the Contractors License taw for the
i p O which following Memo.(Section Ro IS,Business and Improve,
do Professional Code:My city or county
3,2 which requires Issuance.permit re emss ft alley,Wprove,demllli L t ri repair any tumtum
thicer m its censedp"hunt to the the applicant forsuch Con rector'm 0l•signed statement
=�� Hwh uliamedruvanlmNermvisouofdeConua tori Ana Law(Chapter 9 Sq.Ft.Floor Area
VIATFO'W700
9 (commend=gwiLbSecHm7000)of Divisonyaf Ne Busines dPmfewiou Code)or
Hut la h exempt therefrom and the basis for dm alleged eaemptim.Any violation or
Section 7071.5 by myappllnnt for permit subjects the applicant m•civil penally of APN Number Occupancy Type
not tome Than five hundred dollars($500).
0 1,n owner oftle property,"my employce,with wagm astheirsaleampen„uan. 36619076 . 00
will do the work.and the =lure 4 aatinendedaroffered humid(sea704/,Business Required Inspections
and Profesalom Cede:The Consul License Law dose tet apply m m e ns owner of q P
property who lulldeorlmproses Hereon,end whodaasuch work hlmelfor through his
own employees,provided that such Improvements art not intended"Offered for We.It,
however,the building or improvement issold within can year of Completion.Ne owner.
builder will have IN,tarda of proving that he did trot Wild"improve f"purpose of
Wa.).
0 1,As owner of ted property,am eulmively central with Ilcensed ronu"ron to
construct the project(Sec.7044.Business and Prolusions Cade)The Conaaeloes Li-
cease law does not apply m an owner of property who Wilda or improve Ihertan,and, r ii f 1 `� f
w W combats fors"b mojeets with aemuutor(q Ilcemed puraasm m dm Cmuamoh
License law.
0 Iamexemptunder Seo. .B&PCfor Nismason �d+- "'-r'
new DAw
WORKERS COMPENSATION DECLARATION - �� J � �a
I hereby+farm under penalty of perjury one of the following decimations: -
OlinwardwillmsinWnaCWOotea(Cansentmself-imurt(orwotka'.Compere Oi t� I �(�� ��� t�l;n
section,u provided far by Section 5700 of the Inter Cade,for Ne per ..ace of He r�
work for which this permit is Issued.
I have and will maintain Wortres Compensation Inwrma,u required by Section
J W of the labor Cade,for the performance of the works far which Nis permit is iu ted.
My Wo mare on camdermdyNo. numWram_
CArtlei-1 .L/�/lA�l Policy Na.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Auction bond not W completed If the permit is forme hundred dollars(SIM)
or lee.)
I certify that In the performance of the work for which this permit Is issued,l shall am
employ any person in any m mer so As in bccotm subject to He Workers'Compensation
Lawn of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making ibis Certificate of EaemMion,you Mmld
become subject in the Worker's Compensation provisions of dw labor Code.you muse
,JO foMwiN Comply with such provialnu or this permit shall W domed rtv.k.d.
z CONSTRUCTION LENDING AGENCY
F+rvN. I lamby alnrm dust Vert is...'recur kn ling ape"y lir ted anfurmma of
sic work for which thus permit is issued(Sec.7097.Civ.C.)
GQ Lender's Name
z Lattice.Address
U0 1 ceNfy that I lave mad this application and sum that the ecbow information is
U,r! cornett 1 Agra to comply with all city and county ordinances and sure laws relating in
C)rU' building comment and herebyauNorim mpnsenudws of this city as enter upon He
W ecmve-memiumd property for inspection pugmses.
(We)agree to save,indemnify and keep harmkss the City of Cupertino against
0 Ilabilitiu,judgments,cote and expenses which may in my way acme jAi &L said City
U 7 APmsequeaceof the UNDEASTANDS Athis
ND WILL COMPLY WITH ALL NON-POINT �ed by: Date
F7 OU
a/ Re-roofs
Si{nuum of Applicm =tractor Data
H ARDOUSMATERIALS DISCLOSURE
Type of Roof
WIII iwu futureWildng Occupant mare
olaMk haasldoasmaterial
As ded y the Cupertino Municipal Code.Chapter 9.13,and the Health and afary
ado.Section zss32(.)9
All roofs shall be inspected prior to an roofing material being Installed.
❑Yea 1 r+n P P Y g g
Will thea Applicant or future building"cu.ni use If a roof is installed without first obtaining an inspection,I agree to remove
rp g P ea Air equipment
emit havardow air conuminmts u defined by the Bay Area Air Quality Management all new materials for inspection.
'
District?
❑Yes >eQNu
I new
mud lie hvardms materials requirements under Chapter 6.95 of the Cslifm-
nla HcaW&SafuyCode,Sections 255115,25577 and 25534.1 undermnd Its If sic Wilding
does not currently haw a tetnnt that it is my responsibility to tied ry ted acupmt or the
whit stxmctdnrwlss men arOc;Pr O IgnatureofApplicant Date
Owncr"amhomcdegem Dae All roof coverings to be Class„Bre Of better
C