02080012 CITY OF CUPERTINO -¢ r �
BUILDING DIVISION PERMIT CUNTRACTQR4NFORMATION'
2.:??st
BUILDING ADDRESS: PERMIT NO.
20207 BOLLINGER Rn WATER QUALITY PLUMBING 02080012
OWNER'S NAME: APPLICATION SUB DATE
PEVZNER BORIS AND NEKHAMA 1860 ALMADEN RD 08/05/2002
PHONE: SANITARY NO. CONTROL NO.
(408) 267-9330
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
rn 6 a
OS v=mi= LICENSED CONTRACTOR'S DECLARATION Job Description
—O I hembv lamination 1 am licnnssd under provisions of 0m rer 9 fa mmcadng
w wire Section 7(N)01 of Division3 of the Bus unJ Pmlcssions Cede mdse license
�u�� i1afq11 .aaad 3 50 COPPER REPIPE/MAIN LINE
re0 U Liccn.,$eIstss Lic.p
aN etLL Data - Comma"'
0.O rn `` ,, AR HITECrS OEC ION
y�C+Py-1 h S 1 Ondcrs' g'"y Pk arts ah 11 be u c p nl nNs
a+6 o O Lic Tessin ` -
°'x T OW�UILDER DECL RATION `
id-,— 1 hereby umrm that I at exempt from the Commcmr's License Law for the
2< following mason.(Section 7031.5.Business and Pmfesxions Coda:Any city at county $5000
I r❑ which inquires a permit m constrvn,alter.improve,demolish,or repay anY strvnum
umaj3$ prior to its ismance,also requires theappiicant for such permit lilt a signedstafemem S
mat he is licensed lwrsmm nt the previsions of the Contractors License Law(Chapter 9 3 6 9 p` p,tyor,Area Va1LLat10❑
(commencing with Section 7(1(10)of Division 3 of the Business and Professions Cade) 9 5 U 2 5 Liu
or that he is exempt mcrermm and the naris for the alleged exemption,Any violation
of Section 7031.5 by any applicant for a permit subjects the affiliate to a civil penalty
.f.m more than five hundred dollars(S500), 202 Jill 'FLOOR PLLMBING Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation.
will do me work,and the nmnu044,re is not intended or offered far sale(Sec.7p,�,,., �d,7 4a,
Business and Professions Cade:The Contractor's License Law does ant apply m an 502
- FINAL PLt j*ijTCl4D ETMY
owner of property Who builds or improves thereon,and who does such work himself
ar thm.gh his own employ.,.provided that such improvements are not intended m 507 — FINAL PLUMBING
offered for sale.If,however,the building Or improvement is sold within one year of
completion,the owner-builder will have the huNen mf proving that be did nut build or
improvefurpur,t, of sole.).
❑Loa owner of the properly,ant exclusively contracting so wire licensed comment.is �� ����
consumer the project(Sec,9to4L Business and Professions Wild,
in The narratives
lis Contractor's tte�)
License Law docs not apply man owner M a economical)
ny,who builds s improves tato the
who cummcu for such projecm with a commemr(s)licensed pursuant w the
01Contractor's.eraLicense Wet rsOa%I
❑I am exempt under Sec. ,B @ P C for mix reason
Owner Dare
WORKER'S COMPENSATION DECLARATION BV�L��faVIG
I neachy affirm under penalty of perjury one of the following declarations: BUILDING
❑ 1 have and will maintain a Certificate of Comana to self-imine for Worker's
Compensation. as provided for by Section 3700 of the Labor Code, for me
performance of the work far which this permit is issued.
❑1 nave and will maintain Worker's Compensation Insurance,a required by Section
37W of the Wlnr Code,for the performance of the work for which this permit is
issued.M W Tkcrs Compensation Insurance carrier and Policy number art:
`anter.� �_policy l,! j 9 t Lf0�3C�
J' CERTIFICAT FEXEM FROM WORKERS'
COMPENSATION INSURANCE
This section need nm he completed if the Penni,is for one handled dollars
($100)or less.)
I ccnify that in the performance of the work for which this permit is issued,1
shall not employ any person in any manner m as m become subject to the Warkeol
Compensation Laws of Califomie.Data
Applicant
NOTICE TO APPLICANT:It,after making distCamara m of Exemption,you hhould
z bemonambjectmtR Workcrs Cion,loaion pmrisinns ofine Labor Code,you..in
00 forthwith"many with such proviaimnx or this permit shall be deemed revoked.
F .�. CONSTRUCTION LENDING AGENCY
a ' I barely amort that mem is n construction lending agency far the performance
w of the work for which this permit is issued(Sec.3097.Civ.C.)
6x ❑ Li ndcr i Name
-Dz Lendcr's Address
Q
1 calmly that 1 have mad this application and state that the above information istat. 1„i correct,I agree to comply with all city and county ordinances and.state laws relating
0 U to building automation,and hereby amheme repmmmaives of this chyle enter upon
y W the above-mentioned prepeny for inspc.inn proponent.
E+ Pr (We)agree to save,indemnify and keep harmless the City or Cupertino against
h liabilities,judgmen.,cos.and expenses which may in any way vecrvc against said
V z City in consequence of me 8mmiag of leis Penni
APPLICANT UNDERSTANDS ANDWILLC PLY WITH AL1, DN-POINT r+ 't/// C_
' u e Rec 'LA — Issued by: Dale
nature of pplima ammo°r Date Re-roofs
HAZARDOUS MATERIAL DISCLOSURE
Will the applicant or future building occupations,at handle retarders macrial Type of Roof
as defined by Ina Constants.Municipal Code.Chapter 9.12,and the Health and Safety
Coda Seninn 25532(x17
❑Yes No All roofs shall be inspected prior to any roofing material being installed.
Wi 11 the npplicont or Tisco building rccepant axe cgaipment.f devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit haanNous air contaminants as delined by the Bay Area Air Quality Management
DistriC10 Yes V� all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
I have mad the hazadous materials Comm man s under Chapter 6.95 of the
California Health&Sully Code.Sections 25305.35533 and 25534.1 wdemand that
ifinebuildingdaesnm=ualy harentenamJ tit is mY mponsibility mnmifythe
Occupant of the lequiremenu which nm.a be phis to issuance bi i Certificate or
Ove
A �_S�y Signature of Applicant Date
�r an. a Data - All roof coverings to be Class "B" or better
OFFICE