07100103 CIT�' OF CUPERTINO ' ` °
BUILDING DIV1S10N PERMIT �������� ������'���N . :°
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PERMIT NO.
BUfLD �����4 S CARTA BLANCA ST TBD — TC) BE DETERMINED 07100103 •
PERMIT L55UE DATE
'R'S NAME: ,
LARRY STEIN
SANiTARY NO. CONTROL NO.
PHONE:
BUILDING PERMITINFO
ARCHITECf/ENGINEER: gLDG ELECT PLUMB MECH
� � � �
i p p LICENSED CON7RACTOR �ecuRar►oN Job Description
� V� ! hcreby aCfirm that I am liccnxd unJcr provisions oC Chaptcr 9(commcncing
; x� with Sccuoa 7000) of Division 3 of ihc Busincss and Profcssions Cadc, and my liccnsc is HALL BA� �HRM S KYL I GHT � MS TR BDRM RMDL & MS TR BATH
�� a in full Coece and c[fec�
��z LittnscClass ��.�► �� AL RMDL & ��DD SKYLIGHT� ADD SUBPANEL & BRAKERS & CHG
= p Datc Contractor
:�° RCHiTECI'SDECLARATION '�'� o.,,�b•,,, WATER H]�ATER OUT TO TANKLESS & ADD LIGHTING TO
� �
j a a 1 undcrstand my plans shall be uscd as pu6lic rcconLs
)qV
' u. N Liccnud Pm(cssional
. � a OWNER-BUILDER DECLARATION
'r � 1 hcrcby at7irm that 1 am cxcmpt trum ihc Contractors Licensc Law [or thc
� p o following rcason. (Sccuon 7031.5, Busincss and Pmfccsiuns Coc1c: Any city or county
�,°, � which �cquims a pertnit to conswct, alter, impmvc, dcmolish, or repair any swcwcc
�"' y prior ui iLS issuance, also requircs thc applicant far such pertnit to file a signeJ sta�emen� �� Valuation
-? a �at hc is liccnscd pursuan� to thc provisions o[ ihc Contrrcux's Liccnsc Law (Chaptcr 9 .� Ft. Floor Area
r F� (commcncing with Scction 7000) of Division 3 0( Ihc Busincss and Profcssions Codc) or $ S O O O O
i�� ihat he is ezempt thcrefrom and �he basis Cor t�e allegcd ezempuon. Any violarion o(
Section 7031.5 by arry applicant far a pennit subjects ihe applicant to a civil penalty of Number Oeeupaney Type
not morc chan fivc hundred dallars (5500} 3 2 6 1 3 0 4: 3��
❑ l, u owner oC tlu propecty, or my employees with wages u their salc compensation,
will do the wu�1c. and �he stcuauce is not inunded or offered forsale (Sec.7044. Husiness Required Inspeetions
and P�ofessions Cade: The C.onuactor's License Law docc not appiy in an owner af
propeny who 6uilds or improves thereon, and who does such wwk himsel[or �hcough his
own employces, providcd that such improvements are no[ intended ar affered for sale. I[,
however, the building or improvement is sold wiehin one year oC compleaon. U�e ownu-
builder will have the burden ot proving that he did nat build or improvc (or pmpose of
sale J. .
❑ I, as owner o[ the property. am exclusively conuacting wiU� licensed convacmrs w
construct �he projen (Sec. 7044. Business and Pro[essions Code:)'ll� Conuacwr's Li-
cense Law does not apply to an owner of propeny who builds or improves �he�eon, and .
who contracls tor such projects with a convactor(s) lianted pursuant to the Convac[ars
License Law.
❑ i am uempt under Sec. . B& P C for this rcasan
.� Date _.. _
WORKER'S COMPENSAI'ION DECLARATION
1 hereby affirm under penalty of perjury onc of the following declaruions:
❑ I h.+e and will maintain a Certificatc of Consent to self-insure for Worker's Compen-
sation, as provided for 6y Section 3700 of the Labor Code, for the performance oC the
work for which U»s pertnit is issucd.
❑ I havc and will maintain Worker's Compensation Insurana, as rcyuired 6y Section .
3700 of thc Labor Code, Cw thc performance af the work for which this permit is issued.
My Worker's Compensation ►nsunnce carticr and Policy number are:
Carrier. �et� �.t�.._.../ ��, No.: o o 4 y 71 `cZ �
CER7'IFICA7'E OF EXEMPfIOtJ FROM WORKERS'
COMPENSATION INSURANCE
(fhis sccUon need not bc canplc�cd i( the permit is for one hundred doilaca (S I00)
or IcssJ
1 cenify thxt in the performancc of thc work for which Wis permit is issucd. 1 shall not
employ any person in any manncr so as m bccomc subject a �he Workcrs' Compensation
Laws of Califomia. Datc
Appiican�
NOTICE TO APPLICAM: [f, aftcr making ihis CcrtiCca�c of Excmpuon, you should
bccome subject to lhc Workcr's Compcnsation provisions of Ihc La6or Codc, you must
, O forthwi�h comply wi�h such pravisions or this permit sha116c dccmcd revokcd.
Z ""' � CONSTRUCTION LENDING AGENCY
F r�-. 1 hcreby aRirm ihat there is a constcuction Icnding agcncy Cor thc perfurtnancc of
�Y., ��hc work fur which Utis permit is issucd (Scc. 3097, Civ. C.) ,
LL� A Lcndcr's Namc
? � l.cnder's Address
U 0 1 cenily iha� 1 have read ihis application and siatc that �hc abovc information is,
w � cortect. 1 agrce �o comply with all city and counry orefina�es and sute laws relaiing �o
� U building conswction, and hcrcby authori�e reprcscntativcs of Ihis city to cntcr upon thc _'�"
abovc-mcn�ioncd property for inspccdon purposes. -- �
� a (We) agrce �o save, indcmnify and kecp harmless the Ciry of Cupertino against
H � liabiliues, judgmcn�s, costs and expcnscs which may in any way accruc agains� said Ciry � ��
V z in consequence oC �he grandng of Ihis permiG ?�' ='" � Date /�"' , pa(��
� APPLICANT UNDERSTANDS AND W1LL MPLY WITH ALL NON-POINT Issued by �
SOUR R ULA'I70NS. •
,�,� ,.� � 10 !S' 0 Re-roofs -�`�
Signawrc of ApplicanUConuactor �a� T e of R oof '
HAZARDOUS MATERIALS DISCLOSURE YP
Will Ihe applicant or futwe building occupant store or handlc haiardous material
^� dcfincd by �he Cupenino Municipal Codc. Chaptcr 9.12, md the Hcalth and Safety -
�. Seclion 25532(a)? � All roofs shall be inspected prior to any roofing material being installed.
❑ Ycs .
WiII thc app�icant or fuwrc building occupant usc eyuipmcnt or dcvices which
If a roof i� installed without�first obtaining an inspection, I agree to remove
emii haiardnus air contaminan�s u dcGncd by thc Bay Area Air Quality Managcmcnt . a]t ReW jr $ter111S f0[ 1L1SpeCti011.
District?
Q Ycs ��
I havc rcxi the ha�ardous mauerials requircmcn�s unJcr Chapter 6.95 of ihc Califor-
nia Hcalth & Safcry Codc, Sections 25505. 25533 and 25534.1 undcrstand thaz iC ihc building
docs not curtenily havc a tcnan4 �t il is my responcibility ca nou(y U�c a:cupant af �hc
reyuirc �s which must bc mel priar uancc c�r�a� ar o���P��r. Signature of Applicant Date
�, c.�..,, �.,�� ����Ip7 All roof coverings to be Class "B" or better
Owncr or authorizcd agcnt ���