04030122 CITY OF CUPERTINO 9xat�,.rw ''» ''+ °^^
BUILDING DIVISION PERMIT ZONTIM1_1,,INFORMATJON ,
BUILDINGADDRPSS: CENTEX HOMES "'n"'64030122
NER'S NAME: PERMIT ISSUE DATE
CE
.t PHONE: SANITARY NO. 9 CONTROL N0.
(925) 415-1600
ARCHUIECIVENGINSE
4 5-
ARCHnECF/FIIGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
t7_1 0 I� 0
�Oj LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm Nal I am liattsed under provision of Chapter 9(commencing
with Seetien]psI)pf Dlvldon]af dm Budrcu end Pro(eadon Code, my Ecwe4
^� in full tome en d^ae6 li �1CCY( �
job atone clanJ� LIc.0 ?00- � SFDWL-3 STORY (PLAN 3)
LIIIs.... Dam Commoner LIVING 1809/GARAGE 430 SQ FT
ARCHITECT'S DECLARATION
I understand my plan shall he used as public record,
3
5u6
Licensed Professional
"Tom that I MBUILDER DECLARATION
3 a I hmoun .(Siem this I 1 Tempt from 0te Contractors License:AnyC Law for the
o O following wan.(Section IID L5,Budau no we.den on Cmle:Any city structure county
z ti which myuima a penis re cies,he alma improve,demolish,fie a sig ed summer,mer,
z� pow he isliensedpaaant to the heapplicantfor mesahpeter's UIleasi Law(Chapter
< Nuheislianedpuntion7 theW)ofDidonnfNeConucmhnianclaw(CMpuT9 Sq.Ft.Floor Area Valuation
$
(commencingaIsxe pt Section,and it Divisionr of Ote al Business and Professions vi Coda)m
that he m exempt mue(rom and dm basis fa tk alleged exemption.My violation of $200286
Section 7031.3 by any applicant fm a permit subjects me applicant to a civil penalty of APN Number Occupancy Type
not mom Nan five hundred dollen(S5001
p y yp
❑I,as owner of Ne property,or my employees with"Sea as;Neo ale eompena0an. Il rat- q
willdo dmwmk•and NeovucmmpwtinmadedoroEeted for Nc(Sec.70N,Bnineu •(, II,IReq Uircd! p
I0S ections
and Profession Cade:The Contractors Liam Law don not apply to an owner of
property who Wilda or impmeatbereomandwhodmsuchwork himaelfm Waugh his
own employees.provided thatsuch impmvemenbata r aimenOed arolferW fornle.If. ` q
however,the building or lmprowmet is said within as year of completion,the Owner. F,17b0
builder will have Um burden of proving that K did trot build or improve for purptu of
um.).
❑1.as owner of dm property am eaelnively contracting with Evened contractors te
stnn
co me project(Sec.]046,Business and Ptofenien Code:)The Committees Lb
cense law don not apply to on owner of property who builds or improves memon,and,
who contracts for such pmjecu with a contracnr(s)11aned Forward to Ne Contractors - -�I_Jj �•I .�`J�
License law.
❑Iamexemptundm See. ,B&PCfarthismason
an Dam
WORKER'S COMPENSATION DECLARATION
I hereby arras under penalty of perjury as of the following declantlowe
❑1 ham and will maintain aCeNOnmaf Consent in self-insure fm Wohers Comps
sation,a provided for by Section 3700 of the Labor Code.for W performance of the
work for which this permit is issued.
an and will maintain Workers Compensation Imursnce,as required by Section
of tabor Cade.far the performance of the week for which this permit hi house.
orkf/ nmpeas"OM''nsun//ata--artier and Poliq number art: II
Cortef. (=Polity No.:iii��Z ' J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thr sandn need not he complevA if me permit is for one hundred dellats(SIN)
or less)
I certify that in the performance of me work for which this permit B Issued,I Nall not
employ any permn in any reaara as in become subject in Ne Workers Compensation
Laws of California.Dam
Applimum
NOTICE TO APPLICANT:If,army making this Certifier of Exemption.you should
become subject to me Workms Compensation provisions of me labor Coda you must
,JDM
fowith provision m comply with such provithis Permit Nall be deemed mwked.
Z` CONSTRUCTION LENDING AGENCY
E Ihereby.en mthe
laat n a cun a cotutrulending agency for dm performance of
C.>. the weak for which this pnmit Is issued(See.309'1.Civ,C.)
QLanders Name
D z Lender's Add.
C)Q 1 aAfy that I lure mad this application and sum two the show infuriation m
ty ;-! comma 1 agree to comply with all city and county ordinoaes and state laws misting w
N conwclion,and hereby outmost mP.ntativa of mu city in enter upon the
rad aigvcmc judgmcsied property for inspection whichpurposes.
pry (We)sora to mw,indemnify and kap harmless the City Of CYPeNaO aCaint
CA In conses.quent or the
gracing of this
req In any wyasmmagaim said CllY
U7 A PLICA T ofinegaming of this per mit.
•^• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Date
S U ONS
4e-roofs
Sipatum of Appllcant/Co acmr Dam
H ARDOUS MATERIALS DISCLOSURE Type of Roof
Wlllmeappli net or future building Occupant stow or handle harndous material
u derdned by me CupeNno a icipal Code.Chapter 9.12,and W Health and Safety
.seetian zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
Wit
dm applicant or future Pildinti Occupant um equipment On devices which If a roof is installed without first obtaining an inspection,I agree to remove
emlt bemoans air conumi u derived by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes Nu
the not the hmxdan materials requiremema under Chapmri95 of tie Cdifor.
nu Hutth&SafmyCode.SmNom25503.25533ond2533I.lundemandmmifine Wilding
m
data not currently hew a mol Wt It'u my responsibility m nary ma occupant of W
aqqaa which 9u am,etpd tuissuance of 'Bram cu / Signature of Applicant Date
Gaynor or awknired.,nill DowD All roof coverings to be Class"B"or better
r