03050069 (2) BUILDING DIVISION PERMIT qC0TORANFO, RMATION `
.3,n7A ',</ psi.L°s ..•o P>. .w.. Baa,._
BUILDING ADDRESS: MARK PEYSAKHOVICH 111ITNo03050069
0676 CELESTE CT,
WHER'S NAME: PERMITI US7�A'1 52003
ARK PEYSAKHOVICH
PHONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONfRACiDR'S DECLARATION
wCI hereby affirm use,I ann licensed under provisions of chapter 9 burn ocming Job Description
iW with Secubm7IX10)of Division 3af Oc Business and Profiessioes Code,and my license is
^�� mmororcm
License=A REVISION-IN HOUSE USE ONLY
Class; tic.
pro Data C.M.1c, NO NEW PERMIT ISSUED, ORIG. #03040070
°{ ARCHITECT'S DECLARATION
¢ I understand my plans shall be used As public records /2((\
Dau \
3Licensed Pnsfcsaionel
` 3 OWNER-BUILDER DECLARATION
1 rumor sffrtm Nm 1 em ucmpt fromm the ContranDrs License Law for the
F.O O following moon.(Section 71D 1.5,Business and Professions Code:My city or county ✓
K m K which requires a permit to enoawcl.altar,improve,demolish,or¢pair any structure
y prior m is issuance,alau requires the Applicant for such permit w file a signed aaemcnt
< Nat he is licensed p..artwNeprovisions ofthe CootracwriU..Law(Chapter '
r9 Sq.Ft. Floor Area Valu on
¢�$ (commencing with Section 7")of Division 3 of the Business and Profrsomu Code)or
`;.. that he is exempt therefrom and On basis for the alleged exemption Any violation or 0
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than Bvehundred dollars(M). 32658074 . 00 P y yP
D I,As owner of Nees e property.o my employwith wage As their sole compensation,
will do the work and theswcwm is not intended or offered for age(Sec.7014,Business g�
and Professions Code:The Com=mas License law does not apply to an owner of 101 - FOUNDAT a d Inspections
property who builds orimproves thereon,and who docssuch work himself orthrough his
own employees,provided Nat such improvements are not intended coffered forsale,If. 102 — PIERS
however,On building or improvement is to within one yor of completion.Ne owner.
builder will have the home.of proving Nat he did rot Wild or improve for Purpose of 103 — UFER
sale')' 104 - REBAR
I,as owner of the property,am=iwiwly contracting with licensed contractors to
convect use pmject(Sec.70a4.Business anal Prerrsuona Code:)The ConUXWS U. 105 — ANCHOR BOLTS
ennae law mu not apply in an owner ofpmpeny who Wilds or improve.,thereon,and. 106 — SEWER & WATER
who comment for such projects with a e0ntacrosu
Ks)licensed purant w the Ctrx
ontors
Licanxtaw. 202 - UNDERFLOOR PLUMBING
❑Iamesemptunder See ,BkPCfor Nisreason 203 - UNDERFLOOR MECHANICAL
neDate
`
WORKER'S COMPENSATION DECLARATION 204 - UNDERFLOOR FRAME
Ihereby ammtunder Penalty ofperjuryo.cofthe following dxlaradons: 205 - UNDERFLOOR INSULATION
❑ thaw and will maintain a Certificate ofCosem to self-insure for workers compcn- 301 — ROUGH PLUMBING
section.as provided for by Sued..3700 often tabor Core,for the pnforconce of the 3 02 — TUB & OR SHOWER
work for whim this permit is town. 303 - ROUGH MECHANICAL
❑1 haw and will maintain Worker's Compensation Insuranec.az mquised by Section
3700 of Nc labor Code.for the performance or the work for which this pconkis issued. 304 — ROUGH ELECTRICAL
My Workers Compensation Insurance easier and Policy number art: 305 — FRAME
Carder. Policy NFRO 306 - HOLDOWNS
CERTIFICATECOMPENSATION
I NFROMWORKERS' 307 - INSULATION
COMPENSATION INSURANCE
or .)
(Thu section need Act be complexd if ted permit u for one hundred dollass(SIM) 308 - SHEETROCK
I cenicertify Nat in the performance of the work fon which N309 - EXTERIOR LATHis permit is issucd,l shall not 310 - INTERIOR LATH
employ any pctxn in any Manner become ncr az w me subjeco the Workers'Compensation
Laws of California.Dem
Applicant 311 - SCRATCH COAT
NOTICE TO APPLICANT:If,aper making On Cotillion,of Exemption,you should 313 - ROOF NAIL
become subject to On Worker's Compensation provisions of On tabor Code,you mus
JZ faMwiN comply with such provisions or this permit,halt he deemed mwkcd. 501 — FINAL ELECTRICAL ENERGY
zo CONSTRUCTION LENDING AGENCY 502 - FINAL PLUMBING ENERGY
IherobyAM.ft,lMrtuaemurrrcd.nlending Agency for the Performance of 503 - FINAL MECHANICAL ENERGY
a> the work for which Nb Permit u issued(Sec.3097.Civ.C.)
a p Up&,',Nor. 504 - FINAL BUILDING ENERGY
Z) z LAm1c,9Add. 505 — FINAL ELECTRICAL
U O 1 cattily Nat I have read this application and sum Nat the about information is 506 - GAS TEST
ILcorrect.)agree to comply withall city Add county omi ncas and sate laws relating t.
OU building construction.and hereby auNorirempresemnivesofthis city toenter upon OnFINAL PLUMBI G
r I27 ahovcmemioned property for inspection purposes.
G (We)agree N saw,indemnify and keep hnmless the City or Cupertino against 08 FIN L
o-Fr to Iiabilitlas,judgments.core Add exposes which may in my way Accrue against said City 5 I
ofOc
of
C)z APPLICANT UNDERSTANDS A1s Permit.
ND WILL COMPLY WITH ALL NON-POINT Issued by:51 NG Date r
SOURCE REGULATIONS.
Re-roofs
HHAZARDOUSStgnSignature:ofApplic oA_RDOUS MATERIALS DISCLOSURE Dam Type of Roof
Will Ne applicant or future Wilding accupmt store or handle lmamous material
As defined by the C.PAd m0 Municipal Code.Chapter 9.12.and the Health and Safety
.Section 255320)?
❑Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or room building occupant use equipment If a roof is installed without first obtainingan inspection,I agree to remove
(rp C P q 'imam h alevines which P g
emit harardnus air contaminates az defined by Nc Bey Arca Air Quality Management all new materials for inspection.
Dimricl?
❑Yes ❑N.
I have mad the hounds materials req.im....&I Groper 6.95 of the Califor-
.is flrahh k Safety Code,Sections 25505.25533 and 25534.I unnersuvn0 that ifthe Wilding
does cwt curtemly how a=am,Nat its my re,urcAbiloy se notify On eecupmt of On
requirements which mum Wmcl prior to issuance of a Ccinfcaw ofOccupancy. Signature Of Applicant Date
OwnermrmNnrixcdagent Data All roof coverings to be Class"B" or better
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