04020030 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ,CONTRACTOR INFORMATION -:
'�e.,F
BUILDING ADDRESS: PERMIT NO.04020030 4020030
R'S NAME: PERMIT ISSUE DATE
TIMOTHY & VTRTIAXHA STEIN JNE: SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
/('BUDO ELECT PLUMB MECH
nL00 LICENSED CONTRACTOR'S DECLARATION Job DescriP tion 41
OW F I hereby affirm that l em licensed undo provisions of Chapter 9(commencing
`j with Section 9en3 Divisioof the Business eand Professions Code.and my liccnu is
m �o
drmmrce
landaferr«t. 479 SFT
. /REMODEL Q�� O
Z�? License Class Lic.M
nDale Contractor
4 ARCHITECTSDECLARATION
�y8yy IundemanJ my plans shell he used as public records
Oy J D
Licensed Professional ON
��
OWNER-BUILDER DECLARATION
a 1 botchy maso .(firm on 11. exempt(rum the Contractor's o e:Any
Law for the
p O following mason.(Section IIDLS,Business and improve,
demolish,
Code:Any city or county
cimm which its issuance,
ae,alsore cores be alter,improve,deermitt fie a siranystructuo
FZj, pdonnitscensed pocrommq.the lbeision of forsuch Cmum en's License
Low(Chapter
£S< Ihmhctscing it pSalin7 the of Division
the Cnnwnur'snd Professions
Code)or Sq.Ft.Floor Area Valu hon
(cat he is xem with geclion](and hi Division r in the
egeBusiness rr,n im.Any
CnJe)or
Nat he is exempt themfom and the basis for the alleged exemption.Any vlolatfon of
Section 7031.5 by any applicant for a Repair subjects the applicant o a civil penalty of 3a14V-tft gr00 Occupancy Type
not more than rive hundred dollars(5500).
❑I,as Owner of the property,or my employees with wages as their sole compensation,
will do the work,and the slramo m is not intended or offered for sale(Sec.7044,Business
and Profession&Coal The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided lordsuch improvements ere not intended oraRered formic.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sala.).
1,as owner of the progeny,am exclusively contracting with licensed contractors to
onswat the project(Sec.7W.Business and Professions Cade:)The Commetar's Li
conte law does not apply to an owner or property who builds or improves thereon,and
who contracts for such projecb with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑1 am exempt under Sec.
[�. ,B&P C for this reason
er Date 17
/ WORKER' 0 PENSATION DECLARJ(,'�[/�ON
1 hereby affirm under penally of perjury ane of Ihf161[owing declarations:
1 have and will maintain aCcrtiOeam in Consenno self hernia for Worker's Compete
sedan,as provided for by Section 7700 of the Tabor Code,for the perlmnomor of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as nyuired by Section
J]W of the Labor Code,for the Performance of the work for which this puma it is issued.
My Workers Compensation Inaumnce carrier and Policy number am:
Cartier. Policy NO.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed tribe Permit is before hundred dollars(SIOI)
m Icss.)
1 certify that in Na performance of the work for which this Permit is br tied,1 shall not
employ any loosen in any manner so as to become subject to the Workers COmpcneotlon
Laws of Caltfornie.Date
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
.JO forthwith comply with such provisions or this permit shall or deemed rewked.
Z .~�.. CONSTRUCTION LENDING AGENCY
'e. 1 hereby affirm that then is a consomedi n lending agency for the performance of
f.Y. 7 the work for which this perm it is issued(Site 309L Ci,C.)
W Q Lender's Name
CL Lender's Address
( 0 I certify that 1 have mad this application and shote that the above information is
IL F coned 1 agree to comply with all city and county Tornadoes and suite laws reining IO
O V building construction,and hereby monfice representatives Of this City to enter Open the
W .hove-mentioned prosety for inspection purposes.
(We)agree m save,indemnify and kith harmless the City rn Cupertino against /
0. liabilities,judgments,costs and expenses and keep
maytnmy way ss the
ageing said City /
U In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
50y�CEREGULATIO S.
o l h _-6- - t �/3�0',e Re-roofs
nature of App orris tracmr Date
NA ARDOUS MATERIALS DISCLOSUR Type of Roof i
Will Inc applicant Or future building Occupant store Or h eha,vxmxds material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
to,semen zssaxa)] All roofs shall be inspected prior to an roofing material being Installed.
❑Yea �NT P P Y g $
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
coil havardous air contaminants ss JCOned by the Bay Arca Air Quality Management all new materials for inspection.
❑Yes 9No t
1 have mad the harardous materials requirements under Chapter 6.95 of the Calibor-
nie Health ur Current],
Code,tcritiona 25505.2my r spe25534.1 understand th occthe ,of tog
does nal curtendy have a tenant but it is my rcxpoloihility m nntil'y the mcupant Of the
m uircmcn hich muss be met prior ass aCcntficm,of Occupancy.
D� 7_il -�N ;f a���� Signature of Applicant Date
roorannnhorixadagent �^ \ Date All roof coverings to be Class "B" or better