03040070 CITY OF CUPERTINO , " � CTQWa`�I MI�.1.'10 � ^.
BUILDING DIVISION PERMIT & t a „tie' Y �'.; >+�°; '�' t4f" ' -a
BOOSTTO)FUTELESTE CL MARK PEYSAHHOVICH PERMITNO.03r040070
I@MPEYSAHHOVICH �`AfIT�'8Tgg11/2003
SANITARY NO, CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION Job Description
I I hemby Rfflres than 1 em licensed under provisions of Chapter 9(commencing
with Sccdon7=)af Division 3 of the Business and Proressino Code,Rod my license is
I.fall to.andenea. CLOSING THE LOFT
ijR Lianaea.an Ix.R
Dau Corac
nttor
$ ARCHTIECfS DECLARATION
SSSS$ I understand my pians shall bo used is public mmrda
MAY 2 0 2003
Licensed Prefessienal
OWNEm exempt
Fr DECLARATION
1 hereby affirm that 1 em tacmpl from the Cenlnctar'R License Law for six I�
�Go fellnwing news(Sadon 71D1.5,Business and Pmfestlum Cada:Any city m county BUILDING
$ which mqutres a permit m commuct,alter.Improve,dcmulud.a copala
,any nerure BUILDING
Se priormitsissuance.Amrequimnheapplicantforsuchpermlt1n0lesaignedstatement S Ft.Floor Area
g C that he is licensed pumnnuo the provisionsof the Contractor's Ucena Law(Chapmrli q. 11-1Y$tlon
q $ (commencing with Section7000)efDlvlaion Sof the Bminenand ProreuinnsCade)m VU vv
Q .. that he is eaempt Nemflan and the have far den alleged eaempdon.My violation of
Section 7031.5 by any applicant for a permit Subjects the apphmt in R civil Many of Nombw 0 0 Occupancy Type
rut mom also 0w handmd dollen(5500).
❑I,ea owner of the Napeny,or my employees with wages as their Role compensation,
will do do work,and the aunemm hoot intended or offered for sale(See.7044.Business OUND76 dInspections
and Profewmo Code:The Contractors Licese law dos not apply An an owner of
property who builds or improves, 102 = PIERS
w
awn employees,provided dant each lmprowmcn,as not intended or oRamd for ASIA.U. 103 — UFER
however,the buildings improvement Is Said within mm year of ampladon,the owner.
builder win have dm Mount of pmving dot he did nm wild or Improve for purpose of 104 — REBAR
ARM.). 105 - ANCHOR BOLTS
❑1,AS owner of the pmpany,am exclusively contracting with licensed eonuacmn to
comne"the pm)ect(Sec.7044,Business and profession Cede:)Tha Contractor's I.A. 106 — SEWER & WATER
ansa Law does not apply man owner of ,.Perry who Wilda Or bar.Ounces.Rod. 202 - UNDERFLOOR PLUMBING
who contacts for soh project,with comracmr(U licensed pnua
ant motn
the Cetafa
�
c eeLow. 203 - UNDERFLOOR MECHANICAL
ameemtu. «. B@PC n 204 - UNDERFLOOR FRAME
win 205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATION DFiCLARATIO
I hereby An.coda,Poorly of pedury one or the following declaralow. 301 - ROUGH PLUMBING
I have and will maintain Canlfinu ofcemanllo self.insum fmworkefsCanpen. 302 — TUB & OR SHOWER
noon,u provided fa by Section 3700 of site tabor Code.for the Penbsto nm of the 303 — ROUGH MECHANICAL
weak for which this permit is issued. 304 - ROUGH ELECTRICAL
❑1 have
cosi will mainWn WodmrR Compewtion Insurance,u required by Sewan
3700 of the tabor Cndc.fa the performance of as work for which this pa,mu It blued. 305 — FRAME
Myworkeraenmpanewonwmnaa.mer.nePonrynvmxr.m: 306 — HOLDOWNS
Cinder. Policy No.; 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 — SHEETROCK
aids comivnnced net bocomideted role permit,foram hundred dollars($IBM 309 — EXTERIOR LATH
(11f1) 310 — INTERIOR LATH
1 anify,that in the performance of the work For which this permit,Wood,I NAI not
employ any parson in any turner an As to become subject the worken'Cempensanlen ' 311 — SCRATCH COAT
Laws of California.Dam 313 - ROOF NAIL
Applicant
NOTICETO APPLICANT:If.after making this Certificate of Exemption,you should 501 - FINAL ELECTRICAL ENERGY
become subject m the Work=',Cmopeoaden proidem,of Me labor Code,You muss
2 forthwith amply with such provisions or this reamer shun be domed rooked. 502 - FINAL PLUMBING ENERGY
zo CONSTRUCTION LENDING AGENCY 503 — FINAL MECHANICAL ENERGY
(—t taiIhambY Allan that them,.construction lending Attract,for the perfusmena of 504 - FINAL BUILDING ENERGY
w? thewmk
for which this permit,burned(Sec.3097.Civ,C.)
Lenders Name 505 - FINAL ELECTRICAL
A
Z t sin'"sides' 506 - GAS TEST
U O 1 certify that 1 haw mad this applicautu W sum dant the above Information 1.
507 -- FINAL PLUMBING —
Mr 1 ap=to comply with all city and county ordinances and sum laws mining m
L7 buildingconswction,andhemby.uthoriamparmenudwsorthiscitytoenterupontite WFIMECHAIJC:AL
ahovcmen coned properly for inspewon pugtama.(We)agree to row.Indemnify and keep harmless dm City of CupeAno against ��liabilities,judgments.casts and expenses which may in any way¢crue against wd City 5GU Z in consequence of me granting of this permit. DateAPPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NO POI Issued by:5WORKS
SOURCEREG TIONS. 11/
Re-roofs
SI are of Applleans)Contncmr Da
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIN the applicant Or future wilding ooupantamm mhandle ha>ardoes author l
AS defined by de CupeNno Municipal Code.Chapter 9.11.and the Health and Safety
see•s�=um,W31(a)71 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 0[J No
Will the appiianlor/f\uture wilding occupant on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hoa,dnus oilcantsmiona As deBneq by the Bay Arte Air Quell,Management all new materials for inspection.
District] \�
❑YU y No
in avW e mthe hvaNam`mueda,MquitemenuunderChapmrb.95 of the Califon
ni.Health&SafetyCmde,So6us15505.35533md25534.1undcmonddtatifdte witting
does not currently haw a tenant.that It is my responsibility to notify the ocupant Fine
real athentsw M1G wmetpri,Wishuaaar.cwnama�f a Signature of Applicant Date
Ger w Rvthod>ed resent Dem All roof coverings to be Class"B"or better