04030103 CITY OF CUPERTINO
BUILDING DIVISION PERMITsCtl1VTRAC�TQRNFUY2MATT(?V '&
BUILDING ADDRESS: CENTEX HOMES PERMIT N$4030103
r PAINPOW DR 10T 24
ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
ARCHI'IECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� D
ij 0G LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hcroby elfrm Nu 1 me licame d under provWorta of Chapto,9(m ancing p
W!aon70 )of Div Ionl NeB 'ncaa 1i'r stun o rad nm is
in full farm andel r r�
Lme„son 1 LIC.R SFDWL-3 STORY (PLAN 5) �i� ��\,q YIM I[�
. Dem ARCHI'IECI'SContDEC1.ARATION LIVING 1992/GARAGE 430 SQ FT '• ,,,_,[D
1 understand my plus shall he used As public records f�
30 Licensed Professional
OWNER-BUILDER DECLARATION
I 1 hereby affirm that I am exempt From the Canlnctors License Law for the _
i a O following rumen.(Section 701.5,Business and Professions Cole:My city or county II I I
of$ which mquires a permit to construct.alar,improve,demolish,or mpalr any nmmorn
pd.rmi%bmmuc.alsonxsima lMapplicamforauch permi,to Rbasigncdsatemem `./ i, ��i`�i
gg < that he is licensed partner,to the previsions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area V�b gn)`.0/0
$ (commencing with Section 70ro)of Division 3 of NC Business and Profemaiou Code)At
Nal he is exempt therefrom,and the bub for W alleged exemption.Any violN6n of
Section 7031.5 by any applicant for a permit subjects the appimem to a civil penalty of APN Number Occupancy Type
not mom than five hundred dollen($300).
❑I,uowner ofthe lvoprny,mmy employes wird wguutWirxele cempenu0oe, 36619076 . 00
will do Om work.and the motors 6 rte,Intended or offered for ale(Ste.70M,Business
Arm Profecou..Code:The Cnnuxetor's License Law don not apply to in owlly of Required Inspections
prepertywha buildsorimproves Ihomon,and who doesanch work himxelforthrough his
ownemployes,provided that such improvemenuare notinmMM orofftrod for man.If,
however,the building or improvement is sold within one year o(compledon.the owner.
Wilder MB have the burden of pmving that he did no,build ar improve fn purpose of
sale.).
❑1,u owner of the property,am exclusively contracting with licensed commission on
construct the project(Sec.7044.Business and Pmfwiau Code:)The Contractoes u.
cense law doss not apply in an owner of property who Wilds or improve thereon.aM
who contracts for such projects with aeontractorM licensed pursuant to dse Contractor's
Lice.law.
❑lamexemptunder Sec .1161'Cforthiarcuoo
Data
WORKERS COMPENSATION DECLARATION
I hereby arm under penalty of perjury noun of the following decimations:
❑[have and will malntsin.Cenifmmof Cauentwwlf.iosumfor Worker's Campcm
ardor,u provided roe by Section 3700 of the labor Ca .fm ism performance of the
work for which this permit is issued.
d will maintain Worker's Compensulon Insurance.As required by Section
]00 of Ne Labor Cadef �r rmmm AIthnd wart for caber a Nis permit is lasted.
MY Work enss'on ncecamim sod Polity number am- / f
Canis. polity Na: VJ . /Di J
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
CThb sechum need not W camplemd I(tha permit Is form=hundred dollars(5100)
ar ksx)
1 mMC,Nat in Ne psrimmwa of the week for which Nis permit b Wood.I Nall me
employ any person in any manner an u in become subject to the Workeri Compeunlon
Laws of California.Dart
Applicant
NOTICE TO APPLICANT:IL eller making this Centfcam of Exemption,you should
become subject to me Worker's Compensation prevision.of the Labor Code.you must
,JO foMwith comply with such pmWu
veor NW m
is permit Nall deemed whcd.
tiCONSTRUCTION LENDING AGENCY
[—i l hereby affirm that Nen is a ceostruction lending agency for Ne performance of
aiNe work for which Nu permit is issued(Sec.3097.Civ.C.)
Lander',(y 0 Ler',Name t
PZ Lender's Add.
U Q 1 mnify that 1 have reed thin application and cum that the Above information 4
is.;•'. cones.1 agree,o comply with all city and county ordinances and sum law,totaling to
O SV' Wilding construction,and hemby authodm mpmarmati s of Nis city in enter upon the
W above,nomloned property for Impaction purposes.
(We)Agree to save,indemnify and keep harmless the City of Cupertino against
o-.i y7 Imblllims,judgments.emu and expense,which may in any way acrnm against said City
fJ A 'IAnPPLsequence of to RSTANDS Aof tND WI COMPLY W ALL NONPOINT I d by: Date
F7 RE D
Re-roofs
Signe of ApplicenUContnct Dam
HAZARQ US MATERIALS DISCLOSURE Type of Roof
Will Ne applicant or Futuro Willing meupant Roro ar handle KAMM..$material
As Eeflned by the Cupertino uric) 1 Code,Chapter 9.13. e Health and Safety
e.Section 3553x4)7 and NAll roofs shall be inspected prior to any roofing material being installed.
❑Yn
Will the applicant or future building occupant ume equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit ma,z us air contain u u defined by the Bay Area Air Quality Management all new materials for inspection.
moltDisiht7
❑Ye, Nu
Ihave mW the,huardmnsmatermorequlmmmu under Chapmr6.95 of Ne Califor. t
nia Health k Sa(elyCode.Sectiau35505,35533 and 35534.1 understand that!film Wilding
doss not currently how a tenor,that i,is my responsibility m notify the occupant of the
myulmmc w ' must et pdrtoissuaneeo rti0cemafOr P,� ignature of Applicant Date
owner ar.atborivrd ag m All roof coverings to be Class"B"or better ,
L