04030094 CITY OF CUPERTINO + ww
PERMIT �*���}}=*.., v
BUILDING DIVISION PERT W,
�di\4J. 1 �it R
N
, tr'xn
BUILDING ADDRESS: CENTEX HOMES PEaMIT Nb4030094
ER'S NAME: FERMrr ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t
+�Op LICENSED CONTRACTOR'S DECLARATION lob Description
I hereby affirm Nn I am 14sxcd under provision o(Clupur 9(ryn!���ing
¢ wiNSeed TO10)or D'oro Jaffee Bual atp�ift�les�si/nn—�codef,�&n¢lh icert¢B � ��T
^< .full fo¢e�m�J7e Tl ��'�
]g Lka� Lic.a / SFDWL-3 STORY PLAN 3) „
L tram cSDECL LIVING 1809/GARAGE 430 SQ `FT
w
AaCRRn I-s DECLARATION qp
I understood my plan shall be used as public records
5 G Licensed Professional r
OWNER-BUILDER DECLARATION
I barony affirm that I am eaelPr from true Commemers License Law,for Ibe
i O O following mason.(Section 7031.5,Business and profession Code:Any city or county 111`I ��'I ` `✓�
u�$ which re uira a permit m N
canuc4 alter,improve,xmntoin
lim.or repair say Atruc _A
F-Za
prior!its issuance,also requires the applicant for each permit to file a signed summent - -
q < thotheislicensedpumsammtheprovisionsoftheConmcbr'tUmruclaw(Chapter9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Crude)or
Wt he k exempt therefrom and the basis for the alleged emption.Any violation of $210700
Section 7031.5 by tory applicant for a permit subjects the App0un%m A Civil penslty Of APN Number Occupancy Type
not mom than Rra hundred dollars(5300k
❑I,as Owurofthe property,ormyemployw with wegnasfeeirmle eompenxtion,
will dothe work and fee soucWro u not intended or offered for (Sao 7044,Business
Ona Profession tax:Toe au
Conors Lunt! n
Law does ,apply to an Owner or Required Inspections
propenywho build,orimproves feercon,and who doessuch work himselfor Waugh his
awnemployms,provided thin such improwmmuasm not intended oraQentd for Cole if,
however,the building or improvement it said within am you orcompleuan,the owner.
Wilder will haw Use burden of paving wt he did not build Or Improve far purpose of
asm.).
❑1,u owner of the Property un mscluci m floodnt with licenmd.n rarer u
convect the project(Sec.70".Business and Professions Code:)The Contractors Li-
cense law don not apply in an owns of property who builds or Improve Neran,and
who contracts for such projects with seom amr(s)licensed pursuant to the Contractor. .
Licence Law.
❑1 aeacamp unser sec. .B A P C fu thisroasan
r Dau
WORKERS COMPENSATION DECLARATION'
1 hereby 91mm under penalty or perjury am of fee following declaration:
❑1 the
and will maintain A tertians orcoml mal6insure forworkertcompem
urian.u previous!for by Suction 3700 of the Labor Code,for the performance or dm
work for which this permit is Issued.
he
and will maintain Worker compensation Insurance,as required by Section
706 of bor Cot.,for they om ueft of the work for which this permit ts issued.
My orkcr COMM' d sue artier and Policy n/umner am(+Qf
Ca 7 Polity No.: 1!/��� (p —OJ
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thb smilm need not W Completed If the permit Is foranc hundred dollau($100)
or Less)
1 menify that in the performeno of Jen work for which this Permit Is Issued,I Nall nor
employ any person in any manner an u to become subject to ted Workers Compena0an
Lows.[California,Duck
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Eeemption,you&honed
become subject in Ne Worker's Compensation provisions of the labor Cade,you must
.,0 forthwith comply wife each pravions or this permit Wall be seemed invoked.
z tiCONSTRUCTION LENDING AGENCY
F.r I berobY alarm that Nem is...Motion lending apcnry for the performance of
�i the.,it for which Nu permit is food(Sec.3097,Civ,C.)
QLenders Name
z Lenders Adu
dra
U Q 1 cenify that I have read this application and two that the above information is
Ly E corrom i agree to comply with all city and county ordinances and,uu laws meadng to
O SV' building consMNon,and hereby authosim mprennu rms of this city to enter uprn the
W above-mentioned prapeny for Inspection purp.es
LL (We)agree to an,indemnify and kap hamxts the City of Cupertino against
.a N Ilabilides,judgments,costs and expanses which may in any way same&gams%and Cl
in
of the
V APPLICANT UNDERSTANDS AOf rs pCMiL
N2 WILL COMPLY WITH ALL NON-P01 slued by; Date
RE IATIOI, /J
Re-roofs
s' naturco AppliunVCy vector Dam
Fy2ARDOUS MATERIALS DISCLOSURE Type of Roof
Will dmapp xmorfuwrc building occupontuoin orMedkh��dois material
as MRo d by din Cupertino Municipal Codc,Chapter 9.13,and the Health and Safety
Sectionzss255324)?Oyu All roofs shall be inspected prior to any roofing material being installed.
❑Yrs �}No
will fee Applicant or future wilding Occupant ax equipment or devices which
a roof is installed without first obtaining an inspection,I agree to remove
emit huarEaus sir conumintnal. nncd by dm Bay Arta Air Quality Management all new materials for inspection,
DiatrictT
' ❑Yes u
1hawmadfeenu .N memrieumquimmenuundcrChepw6,95ofsicCalirer-
nIaHealth&SaretyCode,Sectio.75505,25533 sort 25534, unxrsuntl thxifthe building
Jaa not currently haw&mnan4 that it u my iturn,m maty the omupmt the
which tea be pri�rm ias ce eceWRC..or c c. Signature of Applicant Date
614
owear ter oufeasis agent Dam All roof coverings to be Class "B"or better