05030043 CITY OF CUPERTINOa + a ` r
Bu1Lo1Nc DIVISION PEIR I a G`ONNjar-,' QR Illalf,0(LMATION
BUILDING ADDRESS: TAYLOR WOODROW HOMES PERMIT"°'05030043
'20120 TOWN rTR T,TT ii POE;
OWNER'S NAME: PERMIT ISSUE DAM
TAYLOR WOODROW HOMES 2300 CAMINO
E; SANITARY NO. CONTROL NO.
(925) 365-3100
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
he 4Gj LICENSED CONTRACTOR'S DECLARATION Job Description
el bunchy"m Net 1 ann licensed under provisious of Chapter 9(cemme-ull P
�Dll.�
th Satino 7000)ofDlvigo of the Busincu and Professious Code.end myliccnse ie
n� ratomeondertett (p NEW CONDO. (19381 -LIV. SPACE)
'z ase.« ARAGE 568 '
ConusnorA CHIIECI•S DECLARA 0 A-5
ill deru my pl a hall be used u public men
is tensed m
OWNER-BUILDER DECLARATION
herchy affirm Net 1 am exempt from We ConlncmYa License Law for the
0 o following mason.secdon 7031.3.Business and Profevsiom Code:My City or County
$ which acquires a permit to coustrucL alter.hnprove,demolish,or repair any structure
prior b its WK18M,Alan"ORM the applicant forsuch permit to file a signed summent
that W is licensed pursuant in the prevision of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
gF G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $241650
C a$ thathe h uempl 0mmfmm and Ne basis for Ne alleged conception.Any vlolatlon of
Section 7D31.5 by my applicant for a permit subjecta the applicant to a civil penalty of APN Number Occupancy Type
not mom then Bve hundred dollars(5300).
❑1,u owner of the property,err my employcn with wag¢u theircele Compeaudon.
will dothe work.and the stmcmac isnnthueded aroRemd farnk(Sm.7061,Business Required Ins actions
and Proposal..Cade:The Contravenes Lfarm iLaw does Oat apply toe an owner of q P
propessywha bulldmrimproves theseon,aed whodoessuch workhmself orthrough his
Own employees,provided thauah Improvements are not Intended aroRered foraale.if. -
however,the building or improvement is sold within one you of comphdon.she owner.
builder will ban the burden of proving Wt k did not Wild or Improve for purpose of
ask.).
❑1,u comer,of Bac property,am exclusively contracting with licensed Commons m
construct the protect(Sec.7014,Business and Profession$Code:)The Conus z U.
cease LAw docs not apply On an owner of property who builds or Improves thereon,and,
who Conwcu for such pmj"with a contecfer(,0 licensed pursuant m the CanlrsetaYa
Licenm law,
❑Ismuemptunder See ,B&PCferthisrcason
Owner Dau
WORKERS COMPENSATION DECLARATION
1 herchy sl(bm under Penalty of perjury on of the following declantious:
❑I have and will mdmeina Codi o ...t¢self-InsureforwodufsCompen-
ution,as provided for by Scion 370)of the labor Code.for the performance of this
work for which this panels I.issued.
❑I have and will maintain Worker's Compensation Imuran.as sequined by Section
3700of The Labor Code.for the performance of the wart for which this permit is Issued.
My Worker's mpenution Insurance Carrier and Policy number am:
Comer. Policy No.: d
CERTIFICATE OF MP11ON FRO ORKERS'
COMPENSATION INSURANCE
frhts section need Off be camplcud lithe permit Isforow Imndrcddollan($100)
or lest)
I certify Not in the perforrnance of the work for which this pumit is Wood.I shall not
employ any perean in any manner an as an become subject to the WarkaW Compemdon
Laws of California.Dau
Applicant
NOTICE TO APPLICANT:If.a0ct making this CeniEcaa of Exemption.you should
become object to the Waiter's Compensation provisions of the labor Coda you mug
O forthwith comply with such provisions or this permit shall be domed sewked.
CONSTRUCTION LENDING AGENCY
,44 I hereby affirm that Rum Is a construction lending agency for the performance of
ai 7 the work fu which this permit is issued(Sec.3097.Civ.C.)
1f3 Q lanames0.
Name
0. z landeh Addme
V Q 1 cenify that I have ad this application and sou that the Dhow infarmnlon u
m
LL correct 1 agree in Comply with all city and county ordinances nd sou laws relating to
O SVS Wilding construction,and hereby aubodm repmaenutiw$of this city an cnmr upon the
W show-mentioned pmpeny for inspection purposes
LL (We)agree to save,indemnify and kap burnkss the City of Cupertino against
fq Iiabilitica,Wgmenu,<osu and expert¢which may In any way acme against amid City
U 7 in
APPLICANT D RRS'TANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
r7 SOURCE REGU IONS, ^ ' _!
i-k YL� Re-roofs
Si num of unUCamnetu Date
HAZA1tD0USMngA AIS DISCLOSURE Type of Roof
applicamorfuwreW occupant one or handle loswcous material
ned by the Cupertino Munn I Code.Chapter 9.11.and the Health and Safety
Code,Sado.23334,07 All roofs shall be inspected prior to any roofing material being installed.
C]Yes o
Will the applicant or future Wilding Occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
It harudnus air conumiusnu u med by Ne Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
lemmings materials requlrcmenu under Chapter h.93 of the Califor-
sarety oM,Seed.25505.25533md25534.1.n&.Mdmirthetmilding
does not cu it ow a unanL Neth a my resporolMliy u notify oceup t of the
Immenu hon at 'orm' ofacarificalma gamey Signature of Applicant Date
wnc Authorized agent p g All roof coverings to be Class nBn or better
v