04030099 CITY OF CUPERTINO 7 ft""a"
BUILDING DIVISION PERMIT CUN�R ft""UI2'` 'MtJ,' 'I
BUILDING ADDRESS: CENTEX HOMES "0 4 0 3 0 0 9 9 04030099
IS RATNRQW T)R (TOT 4)
OWNER'S NAME: PERMITISSUEDATE
CENTEX HO
SANITARY NO. CONTROL NO.
925 415-1
7ARCHITECZ1!NGINEER: BUILDING PERMIT INFO600 BLDG MECH
am LICENSED CONTRACTOR'S DECLARATIONJob Descri tion
1 hereby affirm(hat l em Resume under provisions of Chapter 9(commencing Ation 7")of Division 3of Ne Beat.and Pro(essdou Code,mrd my license is
leaneercec`' SFDWL-3 STORY (PLAN .5)
em. Wc.M
Dam ConncWr LIVING 1992/GARAGE 430 SQ FT
ARCHITECTS DECLARATION
l understand my plans'hell W mud An public records
� U
Licensed Professional
^ OWNER-BUILDER DECLARATION
r o 5i 1 heresy.(Sect that I am exempt from the Contractor's License Law for the
m which
mason(Section]IDIS,Business and are,de tans Code:Any city as county
which requima a permit re wires the
er,alma improv,demolish,fi repair any atmcmm
r i!^n pdonnits iensedp puralssuant
nthe ft prevision nt oftheauchpmmirbie s Law ed(Chapter
gg <
that he is licensed pursuant W Ne of
of the Contractor'smesaLicense law(Chapmr 9 Sq. F[.FloorArea Va Igtgklp 7 0 0
(cat he is(commencingwittSecrfon rom and or Divisl forn 3 of the Busaged cumpt and Prafnssy vi Cods)gon or
of
dui he is exempt therefrom and the buts for Ne alleged eumption.My violation of
Section 7031.5 by any Applicant for a permit subjects the applicant lo!civil penalty of APN Number Occupancy Type
not ream than fist hundred dollars($500).
❑Luowner ofthe
.and property,nmyemployees with wegauak,(rale compensation, 36619076 . 0036619076 . 00
will Pr Newark,end the awcturerammes micantsnded Law
dos not apply on 44.an owner
of Required Inspections
and property
wh W Cade:The ves dem rm,License Law docs not apply lf an owner is I ® q p
property who bmlldwrimprovaNeuron,and whodmseuch work M1imself orNrough his �5�f .
awnempioyces.provided that such improwmenta are not intended aroQemd forsale.if.
however,the building or improvement is sold within one year of complcdon,Ne owner.
builder will have the burden of proving that he did not Wild or improve for purpose or
ale'
1.as owner of die propenY,em exclusively contracting with licensed cmnYaeYln Io FEB.3 1005
co eruct the project(Sec.1V,Busineu and ons Cade:)The,ConuecWri Li- _
whoclawds unotapplyjean ower ofpro y eWildaorant tosta thmeon.and, I ®I
who Lacs for such projects with aco to licensed to the Conuactar'a
License Law.
❑lam aempru Se B&PCrorthismaun
Owner Data 7-1>-0
XER' 0 SATION DECLARATION
he alRrm under peulty of perjury arta o(Ne following declarations: '
ave and will maintain aCenifiam of Consent to self-insurc for Worker's Comp ct-
n,u provided for by Section 3]00 of the labor Code.(m the peRonnena of the
web(at Willett NI!Parrett is 183YCQ
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the labor Code,far the performance of the work for which this permit is iuued,
My Wcomes Compensation Insurance artier and Polity number am: _
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE -
(Thesseclion need notbecamplemd if the permit is form.hundreduallan(Slip)
or less.)
1 certify that In the perforessnec of the work for which this Permit is leaned,l shall not
employ any person in any munerso u to become subject o the Workers'Compmosa0on
Laws of California.Data
Applicant
NOTICE TO APPLICANT:It.after making this Ccnitmem of Excmptian.You should
become subject to the Worker's Compensation previsions of the labor Code.you must
.J O forthwith comply with such provisions or this permit shall be deemed mvnked.
z""' CONSTRUCTION LENDING AGENCY
[-t
4 1 hereby affirm Nal Nem its construction lending agcnry for the per(urmenm of
ai 7 the work for which this permit is Issued(Sec.3097,Civ.C.)
0.W Q Lenders Namc
z Lender's Address
U 0 I certify that 1 have rad this application and Nm that the show information Is
Ipv H comet.I agree to comply with all city and county ordinances and sore laws minting W
O V building construction,and hereby autbodre representatives of this city W color upon ft
4id above-mentioned property for inspection purposes.
(We)agree to cost,indemnity and ices armless the City of Cupertino against
U N liabil1.consequarso of
utlexpenua me yin any way aceruo against said City
O z In consequeece of the"rutin"of N' I.
^-� APPLICANT UNDE D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE
—/5Re-roofs
arc "Ecant/Commolor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
W'It
Ne appliam or rulum Wilding occupant atom or handle haurdous mammal
As&Incd by the Cupertino Municipal Code.Chapter 9.12,and the Hcalth and Safety
Code,Seetien'53,(.)?❑ t PiNa,
All roofs shall be inspected prior to any roofing material being installed.-
Will the applicant or rulers building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hecordons air contaminants u de0ncd by the Bay Area Air Quality Management all new materials for Inspection.
ictl �a��
El Yet (25.Nm
I have read Nehuardoumam imm rasunderchapter6.95oftheCalifor-
-I.Health&SefelyCo&,S.aL 5, 33 and 8534.1 undersand that if the building
does not ct ren ly hew a a a my responsibility W nodl'y tW occupant of the
reyuiromc CI uismancearaceni0eamafoceYaney SignatureofApplicant Date
Ale -7—/ -oy All roof coverings to be Class"B" or better
crura anvad agent Dam