04030254 CITY OF CUPERTINO - ' $M',idr4 :r =% 7 e "'
PERMIT CONCl2A�URINI"ORMA
:BUILDING DIVISION'. ,
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BUILDING ADDRESS: PERMIT NO.
CENTEX HOMES 04030254
NA PFFY 'MyPERMIT ISSUE DATE
2527 eAMINO 1/ E. R"1011 #100SANITARY OL NO.
ARCHITECT/ENGINEER:" BUILDING PERMIT INFO-
BLDO.. .._.ELECT. .- .PLUMB__ MECH
Loo .
LICENSED CONTRACIDR•SDECLARATION Job Description .
Id e
1 hmbY affirm tau 1 oro Ilcenad under provWou of ClaPwr 9(mmmcaing . .. -
withSecres 70f10)of Div 'on3ofthc Buefnrnul9 Pr_ofcuio- mCodn,/nd mYlice�lmu
^�5 iniubSecro ands Ow4 �/(/�3
Sp LucmCl ll.+ SFDWL-2 STORY (PLAN 6) -- - —
eq °He-- �� 7Eeis°PcuaenoN LIVING 2951/GARAGE 453 S4 F'T�C't'?� Q _
'W I understand my plans slWl he used u public moorN - - -•— _ �jvl, % -��(/(.��
36 Licensed Professional -
=' OWNER-BUILDERemsform
US Cone ION
.� I hereby.(Section 11. exempt from the Cssions o License Law for the
p O fallowing mann.(Section Iso L5,Business and Profe:tians Code:Any oily at county
$ixi
which requires n permit ro cnmruer,plot t Improve,deboluh, fl m sigmd mm mnt - Va
y pdormslicensed pursuant
be thilMapions of for Contrarmittoccron,Law
v
g� o
that he ts licensed putmenl w the previsions of the Burin a'a IJmmw law.Code)9 Sq.Ft.Floor Area � //) Va(u3 64840
a (combonciagwithSecfrem ndtheheadieraeallegeden ption.esywaldereOf SS
3 tau W u evmpl ihertamo uM the beais,fw IW alleged exemption.AnY violulon of ��
Section]ml.sny.measle,ntfnrev heabkn.he.ppxanlm.aalpewtY.f APN Number Occupancy Type
nut mom Ilan Rus hundred doRem(S5ML
❑I,uowlvofthepsoprnymmycmploymwitawgetuwe wk ompemdon,
36619076 00
willda da work.end theaVudme tsnatinwniled maRercd 10 an
,
sand Prarewela Coft"noc Courthouses law cocas ant apply w an owner o Required Inspections
property who builds urimprov thereon,and whodocssuchwwkhimselforlhrough his
own employees,provided Net such improvements She ommu nded araRernd forsaie.If,
havens.the Wilding or Improvement issold within one year of completion.the ownes-
builder will have the burden of proving Nat he did not Wild or Improve for purpom of
sa"
1.as owner of the property.am coclusinly contracting with licensed conmemn to
c nawcl Ne project(See.70/4,Business and Probes ons Code:)The Conttacter's Li-
ec
m law does not apply w an owner of property who Wilde or improv wemon,and . .
who contractsfor each pmkcu with a contmoKel llamd punuanl to the Canvamora
Licca ate.
❑lamaemptunder See ,B&PCforlhienuan
Owner Data
WORKERS COMPENSATION DECLARATION
I thereby dffba under penalty of perjury ane of we following declaeuons: -
how sad will maintain a Ccniftaw of Consent to alf-hourne fm WmkehCompen-
sedan,u provided for by Section 3700 of we labor Cade,for the performance of the
work for which Nis permit is IuueQ
❑1 have and will maintain Worker's Compensation Insurance,u required by Section - -
37M of the LAW,Code,for the performance of the work for which Nu permit is issued.
My WorluezC)o�mpen�sation Insuumoce curler and Policy number arc:
Policy No.:
CEKnFlCATE OF EXEMP ION fl OM WORKERS' '
COMPENSATION INSURANCE _
(husemlmn nttd tel W completed ifthe Permit Is foray hundred dollars(SIM)
or lean)
1 ceniIY Net in the performance of the work for which this Permit is issue&l shell not
employ any person in my manrwran u he become subject to thp Workers Compensation --
Laws of California.Dow
Applicant
NOTICE TO APPLICANT:If,after malring NB Ccniricaw of EaemPtion.you should
become subject on the Worke's Compemdon provisions of the Leber Code,yen must
OO forthwith comply with such provisions or Nis permit be deemed mwkcd.
r 0 CONSTRUCTION LENDING AGENCY
[ti Ihemhy 4MM that Nem u•construction lending agency for the porfonnance of -
fY.> the work for which Nu Permit is issued(Sec.3097.Cl,C.)
W 0 Lender'+None
W
Z lender's Adtlmsa
U O 1 certify that 1 how was this application and Stam that the Show information is
U.E correct.l agree to comply with all city and county ordinances and State taws relating m
OU building eanwuction,and hemby Surmise mpmeanutiv of this city to enter upon we
r W ahow-mentioned property for inspection Pwpme
(We)agree In ave,indemnify and keep ambient we City of Cupertino gainst
AA liabllida.judgments.costs and expenses which may in any way acerae against said City
r'..3 7 in consequence of the granting of this permit. -
r1• APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT ssued by: Date
SO G ATIONS / -
Re-roofs
Sign mof AppticanVC or Dow
N RDOUS MATERIALS DISCLOSURE Type of Roof
Will we applicant ar form building acaupanl store or handle hartdow material
ss de0ned by the Cupertino Municipal Code,Chapter 9.11.and the Halw and Safely
Code.Secdon 255320)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yu }(No
Will the sleptwant or future Wilding Occupant ate equipment m devices which 'If a roof is installed without first obtaining an inspection,I agree to remove
I l evmlous air mmanninams u lowed by we Bay Area Air Quality Management all new materials for inspection.
J retrial?
❑Yee Nu
Thaw mW the havardnusmewdb rc
aquirtnenm onderChepwr Q95ofthc Califon
nia Healw&SactyCode.SceWns25505,25533and25534,1undcmndthaifthc Wilding
does not cumentty haw a mint.oval it 4 my rceno t m notify the oceupat of the
cn hiehmua melpriowiuu cam of
Signature of Applicant Date
i
Owner or mtharizeda 1 Dew All roof coverings to be Class nBn or better