04030123 CITY OF CUPERTINO
BUILDING DIVISION PERMIT `Xm, RACTOR TNFORMATTON
BUILDING ADDRESS: - CENTEX HOMES PERMIT ND.04030123
OWNER'S NAME: PERMIT ISSUE DATE
'E: SANITARY N0. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Bores LICENSED CONTRACTOR'S DECLARATION
I fJ 1 hreby affirm(hat 1 ane licensed under provisions;of 0opmr 9(cemmerming Job Description
^� with Section 7W0)efDivi.m3.1'NC Btommm and Pmfesrom Cade,and my lice•,is
in full fmw and effect
z 3 Lemn.CIan Lm# SFDWL-3 STORY (PLAN 3)
^ q LIVING ARcHrrECrsDECLARATION p/y3/GARAGE 499j SQ FT
5�c3S 1 undemeand my plans shall he used as public ucmds
iG Licensed Professional
Oat I am exempt
from
DECLARATION
i9 1 hereby moun.(Sart that 11. exempt from the feama s Cor License Law for the
NO
O fallowing moon permit
t RD I.3,Butner.and Rafueimu Cala:Any oily or ceury
$ whish requires a permit m construct.else[impmw,demolish,m repair any sternum
NO prim m its issuance,alum requires Ne applicant for such permit to rile a signed imminent
< Nn he is licensed prominent in Ne provisions of the Contnure,License Uw(Chapter 9 Sq. Ft.Floor Area Vai,�gt�y0286
O (commencing with Section 7M)of DivWon 3 of Ne Business and Profuasimu Code)or
9 Neth u exempt therefrom and the basis for the alleged exemption.Any violation of
Smdon 7031.5 by my applicant for.permit subjects the applicant a a civil penalty of APN Number Occupancy Type
not mart Nan Rum hundred dollars(M).
❑Las othewo of ad property.or myemployeesoro wagnuthe(role compensation.
36619076 . 00
will do f work and the manure is not me,Licde0 era w it far not apply t oan want
and eanywhobu Cade:The wsthemmns ndwho oro urea not apply a ori owmr of Required Inspections
propertywhoes.provided
Oureethereon,andwho dosarchwit him self altfar am his
awn employee,provided Nem ouch improvements see m year
of
m leered due owner.
builder
huilder,the killing or Improvement Ishelde did am Sear of improve
dueepose of
builder will haw tiro burden of proving Net he did not build or improve far purpose of �S (j,
sets.). �®Lr-, 'I/mm'g3aa .
�L as owner of the property,am exclusively completing with licensed contnetort to ,
LED
construct Ne pmjm(Sex.TOW,Buainess and PmfcWm.Code:)The Conacmr'a U.
came Law does not apply in
m Dumber of progeny o Wilds or Improves,Neuron.and,
who contacts for such prelim.wiNaean reed p=mutathec runictnh C�D `� 2005
License law. t- D-7
❑tun exempt on r Sen .B 8 P C(err Nle reason pmq�� //at��
Owner Data v ������t/ _
EWS SATION DECLARATION Viz��5/�9
hereby efflrm under pcvmtY o(perJury aro of the following dcelaratiom:
eve and will maintaina CeNBcau of Consent to self-insure for WmkehCompen-
on.u provided for by Lon 37M of the labor Code,for the perform.of the
rk for which Nie permit is iuucd.
C]1 haw and will maintain Worhens Camance,u p anoth,huurmyuimd by Section
3700 of Ne Labor Code,for the performance of the work fmwhich this point,is issued.
My Wantons Compemadoa Insuruec carrier and Policy number are:
Carne.. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Carols auction need not k completed ifthe pemot Is furnace hundred dollars(SIM)
or leu)
I cenify that In the perfurmocc of the work for which this permit is issued.I shall not
employ any Nixon in any manner in as in become subject in the Workers'Compenudon
Laws of Celimeria.Dem
Applicant
NOTICE TO APPLICANT:IL efwr making this Cenificate of Exemption.you should
become subject in the Worked Compemedon provisiom of the Lahr Cade,you must
.J O foMwith comply with such prevision or this permit shall k deemed revoked.
z vCONSTRUCTIONIFNDINGAGENCY
(..I I hereby affirm that then is a controetion lending agency for the performance of
lY ti
the wash for which this permit Is issued(Sec.3097.Civ.C.)
W Q Lem1m'a Nemo
7 z Lenders Address
U Q I cenify that I haw read this applicadon and sum that the show informNun Is
ly^ ounce.1 agree to comply with all city and county andleumte and sum Hws relating to
C)rV" building constitution,and hereby auNonre mpocrommivea of Nis city to enter upon roe
W akw-menuored progeny for Wpecdon purymea
LL (We)agree m on,indemnify and keep harmless the City of Cupenum agaiml /v
I,) IlabllWex,judgments,cera4 andexpemu which m any way acme against aid City /
U 7 m eonsegmrce of the gnndng of(his perm
�7 APPLICANT UNDERSTANDS AN OMPLY WITH ALL NON-POINT Issued by: Date
SOURCER TI 7^/r
}} Re-roofs
Si ofA UZARDOU Dem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or fora building oavpant store ar handle hevsrdo is material
u dell d by de CupeorW Munidp.1 Cade.Chapter 9.13,and the Hunt and Safety
caOc,Senion 75s3x(a)7
'C]Yu ,eNa All roofs shall be inspected prior to any roofing material being installed.
C Will the applicant or future building occupant him equipment or dcvicm which If a roof is installed without first obtaining an inspection,I agree to remove
hu mous oit communism,u JcOned by the Bay Area Air Quality Mwgcment all new materials for inspection.
rich
El yes �u
(how roof thchuamo aro mrlaH���000 t en.under Chpmr6.93ontoGlifor-
nia HcsIN&SafcryCadc,Sau�ms 253D �mJx3334.1 unJen.M Nu If the killing
Jac.not cunenllyhaw.. a lt' ty mapomihility m nodl'y the occupant or Nc
requiremen, aseareanerfiesmaraapancy. Y Signature of Applicant Date
r or a hod ager Oele All roof coverings to be Class"B"or better
CITY OF CUPERTINO ,'fir t"pn "w9 �,zu* *` 'yet=•s'" hL'y . �~�' -�
BUILDING DIVISION PERMIT ' GQNT UCTOR INFORMATION. `
areae x>?�r �
BUILDING ADDRESS: CENTEX HOMES PERMIT 104030123
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY yfa I C ROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED CONTRACTORS DECLARATION IobDescription
0 F I hereby affirm Nu 1 am Bernard under provisions of Chapter 9(rornamom ng
ail with Section 70M)of Division Sof the Business and Professions Cc&.and my liccnm is
to D; in full force and officer.
n� LDic.nse Clas I—C. SFDWL-3 STORY (PLAN 3)
ARCHITECTS DECLARATION LIVING 1861/GARAGE 430 SQ FT
�i I undersand my plans shall he used u public ommost
7yU
3
Qv;In
Licensed PnUcssipnel
OWNER-BUILDER DECLARATION
Contr ON
0 q I hereby.Runs Nat I am exempt from the Lbdrans Cess License Law for the
O o fallowing Mason.(Section 71171.3,Basions and PmfOssions Calc:Any city or county
9 which Ota uima a permit an cnnsadret,after,improve,demolish,,repair any structure
FIy prior In its issuance,also requires theapplicant for such permit o role a signed imminent
FFSQ Nu he is licensed pursuant othe pmvisimunfthe Contractor's LiccnuLaw(Chapter 9 Sq. Ft.Floor Area Valuation
dt-g (camme1,asomith Sections ad f basison3 of alleged
exception.
mynnsled,a or
.. Net he Is eaempl Ummlmm and dre bub far tiat alleged eumptlon.My vlobJun of 86
Section 7031.3 by airy applicant for a pemtit subjects the applicant to a civil penalty of APN Number Occupancy Type .
not roam then five hundred dollars($500).
r
❑I,as owner cribs property,or my employcea with wages a their sib compensation,
will do the work,and the structure is matt intended car-offered for ask(See,7044,Business0 0
and Professions Cade:The Contractor's License Law duan not apply to an owner of Required Inspections
Property who builds or improves museum.and who doe+auch work himself or through his
Own employees,provided Oat uch improvements ere not Intended proffered forale.If.
however.the building or improvement is mid within can year of completion.the owner
builder will have the burden of proving mar he did not build or improve fm purpose of
ale.).
1.a Owner of the propcny,am exclusively contracting wish licensed contractors to
construct the project(Sec.7014,Business and Professions Code:)That Conuactoes U.
cense law does not apply to an owner of progeny who Edda or improves thereon.and
who contracts for such pmjcM with a cortractorm)licensed pursuant to mecontsacmes
License law,
❑lamaemptundv Sec ,BkpCfurthiamamn
owmer Date
WORKER'S COMPENSATION DECLARATION '
1 hereby aMmu under penalty of perjury one of the foOowMg declamations:
have and will maintain a Centrist.of Consent to sel&insuro for Worker's Compcm
n.a provided for by Section 37M of the Labor Code%fm me p ammarsme of the
work for which this Permit is issued.
❑1 have and will maintain Workeee Compensation Insurance.as required by Section
37M of the Lab,Code,f,the performance of the.,it fief which mi,permit b issued.
My Worker's Compensation Insurance artier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sec0on need not becompleed if the permit is Aaron hundred dollars(SIM)
Of leu)
1 certify Was in the performance of me wod,fee which this Permit or issued,I shall rex
employ any person in any manner an an to became subject to the Worker+'Compcallon
Laws of C4IKOMIL Dae
Applicant
NOTICE TO APPLICANT:If.are,making Nis Certificate of Exemption,you should
become object in the Workers Compensation provisions of me labor Code,you muss
.J O forthwith comply with such provisions at this Permit shall he deemed revoked.
zyN. CONSTRUCTION LENDING AGENCY
E1herebyaffirm that then is a construction mrmingapmey for the performance of
> the work for which shit permit is issued(Sec.3097,Civ.C.)
WW Q Landon's Name
07 Z Lattices Address
U Q 1 certify that I have rad this application and+ole mat me shave Information is
k, correct.I agree to comply with all city and county ordinances and rota laws relating to
0 building conauection,and hereby authorize representatives of this city to toter upon the
W abeve-mentioeed Progeny far inspection purposes.
(We)agree m ave.Indemnify and temp harmless me City of Cupertino against
nF.r'faA
liabilities.judgments.costs and expenses which may in any way seem against aid City
U in eonseq,nee of she grunting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of Applim nUConwcmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant scam or handle husrdoa material
as defined by she Cupertino Municipal Code,Chapeau 9.12,and me Health and Safety
Code,Section ss532(a)7
❑tins ❑Na All roofs shall be inspected prior to any roofing material being Installed.
Will enc applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
fta'ardhot air conumiaanu is defned by me Bay Area Air Quality Management all new materials for inspection.
ricf7
❑Ya C]No
I hew orad the lemudmn materials requirements under Chapter 6.95 of the Califon
nia Hart"Safety Cade,Sections 27315.25573 and 25534.1 malcrstsnd that ifue building
Jaa not comedy have s tenant,that it is my responsibility at notify the occupant of the
requlrcmem which most be met prior tuWarned or a Cerilicam of OreapaWy. Signature of Applicant Date
Owner sir authorivnd agent Dam All roof coverings to be Class"B"or better