04030255 CITY OF CUPERTINO
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BUILDING DIVISION, PERMIT
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BUILDING ADDRESS: PERMIT NO.
CENTEX HOMES 04030255
NA PERMIT ISSUE DATE
CENTgy HOMES 2527 eAMINO
IS: SANITARY _OL NO.
ARCHITECTIENGINEER: BUII1sIN0 PERMIT INFO -
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Yoj LICENSED CONTRACTOR'S DECLARATION Job Description
�u 1 hereby affirm that I am Ilttnabd under proviatom of Chapter 9(cammcndn{
with Section 7000)of 310sion 3af die Business and Profession Code.10 license is - -
'^ in full forte and eH
5'gb LlcenwCl Lk.g SFDWL-2 STORY (PLAN 6)
Dau comucier
RCHITECTStDFrIARATION - LIVING 2951/GARAGE 453 SQ FT � •�
I undimmed my plans{hall W used is public Wendtit - -•^- '•- —'-`-
D
IG Licensed Professional .. - _ _ .-
O3YNER BUILDER'DEC ComT10N
1 Mason.(firmSect that 1 1. eusin from see Ganm.mara License law for see
x g D following moon. emit t 7fDL3,Business and Professions Code:My city m canny
x S which requires.lunnit to ctmmruc4 slur.hnprow,demnlW,or repair any sWtlum
to y prior to its issuance.also requires Weimplicant for such permit to file a signed stammenl i.
'- < tWluislimnwdpuml{ntmdlepmviammorweeonu.emraumnsel.w(Chapmr9 - Sq.Ft.Floor Area .(/t1 " ' VauaCo
QqS ry
a a (commencing with Section 7000)ofDivision 3aftheBasmentProfes.ionsCode)or 3 840
that he R except therefromand time hash,for the alleged cumptlan.Any violation of
Section 7D3Lsbyaryapplicant for aamtn.nbjeetsthe.pplkanuo.chill pm.ItyofAPNNumber `c�JpancYl}'Pe ,
not mom than five hundred dollars([500). ^
❑I,uawmwr of the progny,mmy employees with w{esastfuh seta campensdm, SCJ§ Xliw
will do the work.Bud dicaromnrttsantinundedmoffered m...k(sec.7D44,Basi^e,• '� Re uifebIns ecti60"
and Profesalans Code:The contractor.Limas, m law daant appy m an owner or - `9,..r P -
propertywholwildsarimprowa lnersimand whadoessuchwork hlmselrwJuough his -
ownemployees,pmvidedthwwchimprotemmuamnotini,nd oroReredfmaale.IL
builder ill Wildin[anden o wmentlssot the did Ma
of mmpkum,Neownu- /'
builder will Mw the Wrden of proNng that he did not Wild or Improv for purpose or
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ole.
e:
h,as owner of the property,am wclwlvely com acting with licensed comirearn W
comment the projem(Sec.7044,Business and Professions Code:)The Cama Imes Li- -
am law dons not apply 0 an owner of property who Wilda or improv themon,and
who contracts for such projects with a commuctor(s)licensed punwnl to the Contractors
Licensn law.
❑1 an exempt under Sec. .B&P C fns this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury me d the following declared.
hawand will maintain.CmlOwu afConsent u sel6insum far Warku'a Compes- .. ...
anion,u provided for by Section 3700 of the labor Code,for the performauc.of die -
work for which this permit is Issued.
❑1 haw and will maintain Worker.Compensation Inswanm,unaltered by Sedan - .
3700 of Ne labor Code,for shc pmformanca of she work for which Nispermit i.issued.
My Workk�;.�4r�.,sC.cupp'ee�u{uwl r.nceearric and Policy number am:
Grticr�LY�✓! Poliq No: .. -
CEKTIFICATE OF EXEMPTION FROM WORKERS' -
'- COMPENSATION INSURANCE '
n his semim and not bccampleud if the Permit Is foram hundred dollars(SIM)
Or leu.)
1 cenify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner at to becomesubjecl to the Workers'Compensation
Law.of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Otrtifmwu of Eumridua,you should
became subject In the Worker's Compensation provisions of the liber Code,you main
,JO forthwith comply wishsuch lminatons or Ni.permit Mail W dmmd Wvmked.
Z� CONSTRUCTION LENDING AGENCY
[.r Ihorwhichithi she dart is a lending7.Cil.C-) for the perfurmuwW of /
!Ya 4 the work for which this permit b Mama(Sec.3097,Civ,CJ
W IM Lender:Name
Z lender's Addmu
V I«reify that 1 have mad this application and sum that the.how Information is /
D.F coma I gree to comply with all city and county oNWnar and sou laws Wieling 19 O�
O V buildingcons tion.udhembyauNorimmpmunwiwsofshiaoirywenmrupnn the
W above-mentioned property for inspection purposes
G (We)agree to sew,indemnify arb keep harmlesa the City of Calamine against
0 liabilities,Judgments.costs and expenses which may in any soy mean against said City
U 7 In comcqucnm of the$noting of this pcm h.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
EGULATIONS.
We-roofs
Signature ol'Applican octet Data Type of Roof
AZARDOUS MATERIALS DISCLOSURE
Will We applicant or future Wilding occupmt mom or handle huardous material
as dented by tW Cupertino Municipal Cade.Chapter 9.12,and the Health and Safety
Code.SectionM32M)7 ` _ All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or ff'u�wW Wilding acceptor,um equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it h{wrdow air conmminants u defined by W Bay Arta Air Quality Management all new materials for inspection.
huict7
C]Y. AN.
I haw mad the Murdms materials mquitemenu under Chapurii.95 of thc Califary
nia Hcalth@ Safety Code.Sedons 25505,25533 an125534.1 undemund Natifthe Wilding
dean not currently have a unml.that It is my re.powlMlly to notify the necupanl of Ne
aim cntawhichmustheme 'ormiu CertlBcamoroccuP. ignature of Applicant Date
owner onuNofic cram / Dam All roof coverings to be Class"B"or better