04120100 (2) CITY OF CUPERTINO PERMIT /' p ;` �'
BUILDING DIVISION - - CONTRACTQRANk'V ' AT
BUILDING ADDRESS: PERMIT Ncb 4 12 0 10 0
20600 MURAN V
OWNER'S NAME: PERb117LS5UEDATE - - -
CENTEX HOMES
ONE: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
+�aoo LICENSED CONDUCTOR'S DECLARATION O O O O
7, I hereby arm that 1 am licensed under previsions of Chapter 9(commencing Job Description
wild Stttion]IXk))o(Diviaidn3of Ute Budncssasq Profcavom Code.and mylicenmis
�;E
„R. in full to=and effect. TEMPORARY POWER PERMIT
y r3 License Clan Lk.N
Dow Contractor
Z�Z ARCHITECTS DECLARATION
K 1 un&=nd my plans shall be used As public meads
G.�yU
o Licensed Pnsfmsidnnl
OWNER-BUILDER DEOn CoduION /
s I 1 hereby aRrm that 1 am recmpt from de Contactors License law for the
00 following mason.(Sectiun 7031.5,Business and Pmfcsaiuos Code:Any city or county
ie m which requires a permit to construct.cher,impro e,&MORAN.or mpair any suuemm
=y prior to its issuance,also requires the applicant fasuch permit to rile a signed statement
i< ttutheislicensedpursuantintheprovisionsoftMContractor'sLicenselaw(Chapkr9 Sq.Ft. Floor Area Valuation
st~3 (commencing wild Seldom]OW)of Division 3 of On Business and Professions Cole)or
_
that he u esempt therefrom end the baso for the alicgcd Gumption.Any violation of
Section 7031.5 by any applicant for a permit subjdm the applicant In e civil penalty of
Ads more man five hundred dollen(aSEo). e�0 - - Occupancy Type
❑I,As ownerofthe property,ormyemployces with wagmas drelrselecompenssdon,
willdo the work,and meaumoute land,inteMW monered fursale(Sec.70ea,Business
and Pmfcssimu Code:The Conuacmrs License Law does tet apply in An owner of Required Inspections .- .. .. ..
propenywhd build,or improves drereon,and whodoessuch work himsalf mthmugh his
Own employees provided that such impmmments art not intended oroRael forsak.If,
however,the building or improvement is sold within one year of compkuon.the owner- -
builder will have lde human of proving On,he did not build or improve for putpom of
ask.).
A mwmr of a property,.Business reclusively comrstnal wild t)The C mmund!s i-
me La the es jot (Sec.o Ad d,ofand Professions code:)The Conuamon,Li-
come
d
ceox law doth fiat apply to an owner of Property who builds of improvm Norton,and
who contracts per such pmjecu with wonuacmr(s)licensed pursuant to the Cdntrxtora
Lkerrm taw. /// '
❑lore excmdt undo 5tt. ,BkPC for this mason
O yI/e//Ifs)_/) Ls'r as 1
WORN
'S COMPEN ATION DE tARA�IO/t,1/
1 relay aRimr under penalty of perjury one of the fo116wing declamiom:
I hem and will maintain u Ccrtifimte of Consent m sel6imurt for Workcr'a COmped-
aa,ian,as pmvid for by Section 3]00 of the labor Codc,for the performatee of the
-111
ork for which thin permit is issued.
❑1 In
and will maintain Worker;Compertsauen Insurance.As required by Section
3]Oodf the tabor Code,for On preform reeof me work for which this permit is issued. --- --- - - ___ .-.._
My Workers Compemation Insursdee tarricr and Policy number am:
Carrott'. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This semen decd not hcemnPlowd lithe permit is(mane hundred dollars(111) -
Icss.)
1 certify Out to Oc perfmmarcc Of ldc work for which this permit is issued.I s111 not
employ any person in any mannerse As to become subject in he Worker;Compewtidn
Laws of Caifomia Dna
Applicant -
NOTICE TO APPLICANT:IL after making this Ccrufimte of Eacmplar.you should
beceme subject to the Worse,,Compensation provisions of the labor Code,you mum
.J z forthwith comply wuh such provisions or mil permit shall be dcemcd revoked.
Z Q CONSTRUCTION LENDING AGENCY
�-+� I hereby afrum mat inert is construcdon lending agency for me performance of
C' the week for which this permit Is issued(Sa.31197.Ci,C.)
IT]A I.endcrs Name
z Lender's Addnev
U Q 1 certify that 1 haus mad this application and Marc mat the above information is
0 II, correct.I agree a comply with all city and county ordinances and sato laws relating to
building construction.and hereby authorim represenatises Of this city NO cnmr upon the
F,A ahovomentionedoM.ed for inspection puWwhich Ms.
C3. (We)agree m Anus,indemnify and keep hamtkss the City of Cupcnino against
Z in...quc ,G Of On eosaand cal.Oil FoOlLt.which may in anyway M.against said City
C) z A APPLICANT
ofinegamingof thispermit.
^ APPLICANT LATIONNOERSTANDS AND LL COMPLY WITH ALL NON-POINT Issued b
sQURCEp,E LATIO`� �,f.�� Y Dat
y/b//07),�2
\U / '"'� TPS "°^ //�L! Re-roofs
1y A phcan nuaaor a Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or foam building oceupnot mart m handle hazardous material
as defined by On Cupertino Mudici 1 Codan
Code.Chapter 9.12,and the Health d Safety
ode Section 25532M)?
❑Yin No All roofs shall be inspected prior to any roofing material being installed.
Will On applicant or future ildm Occupant use a ul If a roof is installed without first obtainingan inspection,I agree to remove
pPequipment or devima which P
mit hazardous air anuminana cfincd by the Bay Arca Air Quality Managcmcm all new materials for inspection.
I
❑Ym1 have real dm NotA dusoolorMa mquiremcdaunderChater6.95dfdm Califonu Health A SafctyCode.Savors 25505.25533 and 25531.1 undersaM matifde building
ere of currently m a enan4 mat it u my responsibility m notify the occupant Of the
y remenrswhic the tpri issuance of cnifea (Occupant Signature of Applicant Date
'tuff 8�, f pyla/
wde r awl mise agent D,te All roof coverings to be Class "B"or better
Community Development
10300 Torre Avenue
I
31� Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
�UPEI�TINO
Building De artment
JOB ADDRESS: PERMIT #
/ O1.112D0 oO
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR c co ��.� FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the followinginformation:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
ectrical X201,, �
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Conctor Signature Date
CITY OF CUPERTINO
Salo; -CUPEkTINO PERMIT A PLI® ION FORM
ER
CITY of
APN# Date:
62
Building Address:
Owner's Name: Ph o e #:
Contractor Phone: License #:
Contact: / Phone: Cupertino Business,Licebse #:
Building Permit Info:
Elect ❑
Job Descriptionj
Residential ❑ Commercial
Cost of Project:
V
Qty. if
AppI' le Fee ID Fee Description Fee Group
EMP Temporary Power ELECTRICAL
ERMITFEE Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
# 7�