04080048 CITY OF CUPERTINO '^ �?' r,r*et��r`r:r rr'' `"�'- >+ °
Buu.Dlrvc mviSIG PERMIT CONT.RACT0RINFQRMATION.( �
BUILDING ADDRESS: STEVEN SANESKI 1E1MITND04080048
OWNER'S NAME: PERMIT ISSUE DATE
IE; SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
upQ LICENSED CON'TRACTOR'S DECLARATION Job Description
til❑❑ 1 hereby affirm Nal I am licensed under provisions or Chapter 9(commencing p
Z with Sccboo7")of Division 3 of the Business and Profeassio,u Cade,and my liecnan is
no inmRmmaand arr `
Class REVISION--ROOM DIMENSION
j no L full r
Dam Lic.X Contractor NO NEW PERMIT ISSUED/ORIG. #04060263
'rt ARCHITECT'S DECLARATION
1 understand my plans shall W used an public records
Oyu
u.H
Licensed Pmfcssianal
OWNER-BUILDER DECLARATION
J 1 hereby.(firm Our 1 am exempt from thd Contractor's :Anyc Law for IW
00 fidlwhich
ores a Fcccuun 7031.5, alter, nprand tie,dcaroli CWC:repair
any
Or muure
ai m which rtyuires a permit m cnnismct,alma improve,demolish,m repay any xwnum
''t"^ prior o its issuance.also requires the applicant for such permit to rile a signed statement
That he is liccnscd rursmnt to the provisions of the Commctor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
an (commencing with Semon]")of Division 3 of the Business and Professions Crum)or 39
no _ Nat he is exempt IWmfrom and the basis for the alleged exemption.Any violation of
Section]031.5 by any applicant for a permit stioncu the applicant to a civil penalty of APN Number - Occupancy Type
not mom Nan five hundred dollars(SSW). ,
0 1.as owner or the propery,or my employees with wages az their,xale compensation. 316 2 9 018 . 0 0
will do On work and the xwmu a is not intended or offered fatten(sec.7044,Businm
W nt
and Premium Conic:TCoractorLaw does License Ladoes nut apply to an owner of Required Inspections
property who builds or improves thereon,and who doexsuch work himself or through his
Own employers,pmvidcd Nat such improvements are not intended or offered rot sale,if,
however.the building of improvement is sold within one year of completion,he owner
builder will ban the burden of proving that he did not Wild or improve for purpose of
salt.).
0 I,as owner of the properly,am exclusively contracting with licensed contractors m �aa
oatmct the pmjeCL(Scc.7W.Business and Professions Code:)The Contractor's U. p "l
taus,Law does not apply to an owner of progeny who Wilds or improves Neuron,and
who contracts for such projects with a eontnn ir(s)licensed pursuant to IW Contractor's
License law.
L I am exempt or Site _ B&P C for this mason
Owner Da¢ WW a L_
'
WORK COMPENSATION DECLAR
I hereby aRrtn under penalty 0f perjury one of dte f docianni..
bavc and will maintain a Certificate of Consent m elf-insure for Worker's Compen-
wortas provided for by Section 3700 of the Labor Wr Code,for the performance Of the
for which this permit is issued.
0 I have and will maintain Worker's Compensation In....az required by SecuOn
)]o0 of me Labor Cam.for the performance of the work for which this permit is issued
My Worker's Compensation Insurance Manor and Policy number am:
Cartier. Policy No.:
CERTIFICATE OF EK EMPTION FROM WORKERS'
COMPENSATON INSURANCE
Thissection need not be completed if the permit is foronc hundred dollars(Stoll)
to Icss.)
I certify that in the performance of IM work for which this permit is issued,I shall not _
employ.,N onmanymann soazm Wcomc
IF London
Workcri Compensation
Laws mf Ca'far ' am
App ltnim
NOTI E APPLICA f,after making this Cenificen of Exemption.you should
We an ubjen to the Worker's Compensation provisions Of the Lahr Cods.you mot
.�z. fm comply with such previsions ar Nis permit shall he domed revoked.
z i CONSTRUCTION LENDING AGENCY
(r I hereby affirm that then is a co caress inn lending agency(nr the performance of
(La the work for which this permit is issued(Sec.3097.Civ.CT
U Q Lenders Name
u denress
s Add
U 0 1 certify Nat I have read Of.application and stem that the aWre information is
Iy P correct.1 agree to comply with all city and county ordinances and sum laws relating to
0U Wilding construction.and hereby anthonre repracrateven or Nis City to enter upon the
�W shove-mentioned property for inspcndon purpose&
4. (We)gime m cove,indemnify and keep harmless w y as ru Cupertino against
liabiliti(We)g agree
to case,indemnify
expemnif y and keep
may in any ss the C ty Of againesaid City
U Z in consequence of the granting of this permit.
�-^ APPLICANT DERSTANDS MNL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCER ON / Q
Re-roofs
sr of Apprcan✓ actor
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant OF future building Decupaot earn or handle harallous material
az defined by the Cupenim,Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25332(a)'
❑Yes f]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or f77utture Wilding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
haxardnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
4an'?
❑Yes I�No
1 have mad the harardeas materials requirements under Chapter 6,95 of dm Califon
ria Heath&Safely Gat,Sections 25N)5,25533 and 25334.1 undcrsund this it dm Wilding
does not Corte y am a moa than is my responsibility to nnufy like occupant of the
r ants pnortoomee0reeenifv9mor",am,. Signature of Applicant Date
0 rr authm i,dag'em Date All roof coverings to be Class "B"or better