05030085CITY OF CUPERTINO
TFION
BUILDING DIVISION PERMIT.-,CUIVRACTOR�`I,Nk'vORM
BUILDING ADDRESS:
TAYLOR WOODROW HOMES
PERMITND'05030085
OWNER'S NAME:
PERMIT ISSUE DATE
E;
SANITARY NO. CONTROL No.
925 365-3100
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1= I�
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm Net 1 m licensed under provisions of Chapter 9 (commcndng
with Section 7") of Division 3 of the Buuneuaed ProfesIsi�on Cpade1.aed my liceue is
LicenseorI and affect,
�� o
NEW CONDO. (17421 -LIV. SPACE)
Uc 0
D.m canuamom
GE 515' '
ARCHITECfS OECLARAT N
B-25
on n lens W uud u u
¢sussed Priftfilmad
OWNER -BUILDER DECLARATION
hcmhy affirm Nat I am exempt from tiro Characters License 4w for the
ollowing retson. (SmUun 7(171 d. Business and professions Cade: My city or county
which requires a pewit to con sumt. alter, improve. demolish, or repair any stsuctum
prior m its Issuance, also requires the applicant forsuch pewit to III.. signed auremcnt
that W u licensed famunua the pmvulonof the Common's U.. U. (Chapter 9
Sq, Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Busineuand Profevian Code) or
$217333
that he t/ except therefrom and sm basis for the alleged cxempUan. My violation of
APN Number
Occupancy Type
Section 7031.5 by say applicant for a permit subjects the applicant m a civil penalty of
not mom than fro hundred dollars ($5001
❑ 1, as owner of tie property, or my employees with wages as their sole compensation.
"-Required
will do the work and the swnum 4 not intended or offered for sale (Sec. 70/0, Band.and
Prelusion Cade: The Conbwtoh License Law does not appy m in owner or
property h.Wild.., Improves Umrece.an i whodoesauch work himself or Uuough his
awn employes, provided that such improvement, ale not intended araffertd for sale If.
however, the Wilding or improvement is sold within one year of completion. the smer-
builder. will have the Wrden of proving Net o did not Wild or improve for purpose of
isle.).
1, se owner of the Property, am exclusively convecting wish licensed contractors to
construct Ne prokm (Sec. 7004. Business and Profession Code:) M Convector's Lt.
cause Law docs not apply 0 an ower of property who Wilds or improves thereon, and
who contract/ for such projects with •eoncommr(s) licensed purwanHo the Co ata ctofs
License Law.
❑ 1 m exempt under Sec. . B At P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following decimations:
haw and will malntMin a Cerdfiam of Consent romlbiuum for Workers Camper.
station. as provided for by Section 37M of the labor Code, for the performance of the
,
work for which this Permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code. for the Performance of the work for which this pewit is Issued.
My Worker's Ca�mponst tion Insumauchcarrier and Polity number are: Q
�1�OQ�
Cavier.�� f.� Policy No.:
iil-(.TlT
CERTIFICATE OF EMPTION FROM WORKERS*
COMPENSATION INSURANCE
trials xeNa nerd net W conplemd iftie pewit Is fmaeahundreE dollen (5100)
or mss)
1 cenify the, in the performance of the work for which this pewit is issued. )shut new
employ any person in any moneran as in became subject to ted Worker' Compensation
laws mCuifomm. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Ceninate of Exemption, you Mould
become object to Ne Worker's Compensation provisions of the labor Code, you mut/
forthwith comply wish such provisions or this permit shall be deemed rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem Is a censtnctian lending agency for ik Performance of
the work for which this pewit is issued (Sec. 31197. Civ. Cd
Landces Name
Lender's Addams
1 certify Nat 1 have rad this application and sum that the Move InformWun is
covet. I agree to comply with all city and county andmawxund Mum laws mining be
Wilding constriction. ad hereby wthaum representative, of this city to chum upon Ne
above-mcntonW properly for WPeetion Purposes
(Wc) agree to save, indemnify and keep humless the City of Cupertino aisinst
liabilities, judgments, cats and expenses which may In any way acmoe against said City
i Ne granting o(Nis pewit.
LICA DERSTANOS AND WILL COMPLY WITH ALL NON -P INT
Issued by: Date
SOURCE RE LA 5.
-7
Re -roofs
Type of Roof
B nYfC plicmUCanwcmr Da
HAZARDOUS MATERIALS DISCLOSURE
I the applieam or fumm Wilding occupant store or lundk huardous material
used by the Cupertino Munici ode, Chapmr 9.13. end the Halm and Ssfmy
Cents. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yu
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ne applicant or future buil occupant use equipment or devices which
harardnua sit contaminants u used by the Bay Area Air Quality Management
all new materials for inspection.
District?
[3 Yes u
I haw mW the huardnts materials requirements undcrChimer 05 ofThe Califor-
h rycade.sectiaits25505,255»and 25534.1undemmdshatifrW Wilding
an a have untie Nat it 4 mymspreshility in easily she acuP of the
m cern ich be met prior an issuance of&CcrsiRamar apanc
Signature of Applicant Date
All roof coverings to be Class "B" or better
owns¢ ar thonmdegcnr ase