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08010048 CTTY OF CUPERTINOy� y BUILDING DIVISION PERMIT OONI CTAL\INVID r eu1PERMITNO 1018ADDRESS: 5MPIRE AVE TBD - TO BE DETERMINED 08010048 OWNER'S NAME: PERMIT ISSUE DATE RICK BLESZYNSKI 01/09/2008 NE: SANITARY NO. CONTROL NO, ARCHIECT/ENCINEER: BUILDING PERMIT INFO O O PLCO l� 06 LICENSED CONTRACT'OR'S DECLARATION rd I hereby alarm that 1 am littered under provisions of Chapter 9(commencing Job Description x with Scclion7")of Division 3 or the Business and Profession;Code,and my licmue is TEMPORARY POWER POLE ❑<N in full tome and effect. 2 L 2 License Cl. Lic.N Date Contractor ARCHITECT'S DECLARATION I understand my plana shall the used as public records � U 5 Licensed Pnt@uianaI OWNER-BUILDER DECLARATION <� I hereby aRm that 1 am exempt from the ConuactoYa License Law for the p O following mason.(Section 703 1.5,Business and Prefasriom Cate:Any city err county $ which mquima a permit to convect,slur.improve,demullah.or repair any surnmure iy prior to its issuance.else requires;the applicant for such Permit o file a signed suument S� toot be is licensed pursuant o the provisions of thm Convenor's Licence law(chapter 9 Sq.Ft. Floor Area Valuation 5 (commencing with Section 7000)9 Division 3 of the Business and Prefw $ions Coun)or 141 '3.+ Nat he u aampt therefrom and me basis for dut allegmd exemption.Any violadon of Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penally ofNber Occas not mom than five hundred dollars($5M 3262202'9 umOccupancy Type C Luawner ofthe property,or my employes with wages as their sok compensation, will da IWwork anile: at Catunots Licemde Law dosnota(Set.R)44,Hudwe end property bis Code:The Convector's License Law deet not apply lf an owner is Required Inspections oweeny who WIprovid mpmvm demon,and who are aroelfedIhmugh his how a however. the or that ventuch improvements art not year ofA arced ed forsale.the own If. however.Nebuildingor improvement4alt wilhlnone ildofimroeforNeamter- builder will have the huNm of proving that bo tlltl not Wild m improve far purpose of sale.). C 1,u owner of the properly,am exclusively mntratieg with licensed mntrecton to convect the pmjcm(See 1044.Business and Professions Cade:)The Cmmoner's U. cane law does not apply b an owner of property who builds orimpmves Neonan,and who contracts for such projec ire a mnuactor(s)licensed Panama to Ne Contractoh Litems Law. /I C 1 ern eaem Qn,See ,B&P for amount Owner v� Date D WO ER'S COMPENSATION DECLARATIO 1 hereby affirm under penalty of perjury one of du fallowing declaradam: Wireand will maintain•Ccr rlcamof CementOself-InsurefmWorYcr'sCampen- an,as provided for by Section 3100 of the labor Code.for me Perfor .of use work:for which this permit is issued. C I have and will maintain Workeri Compensation Insurance,as recruited by Section 3100 ofdm Labor Code,for Ne performance ofine wolt formich this permit is taunt ' My Worker's Compensation Imermce carrier and Policy number are: Curer. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS COMPENSATION INSURANCE (Dissection wand rot bo completed lithe permIt is forum hundred dollar;($100) or kis) I certify dal In the performaof the wq9''it for pP'hich Nis jO�mit is issued.I shall not emplayany Pe anym�nnerm�ts lq'hgpn96m�t 4 Wmkers'Compereadon ' Laws fC� ,IIIc( D� UU - NOTIC LIC .If,aRor making this Cerlificae o!Exemption,you should - - become so feet to the rsees Compcnndon provisions of the Labor Code,you mora ' wJ 0 forthwith comply with such prorisiom or,this permit sill bo deemed mmked. a" CONSTRUCTION LENDING AGENCY [--m Thor which Nnmem its cmmmn.30 len ding agency for the perfurmamx of .� the work for which mu permit u iamtl(Bac.J097,Civ.C.) QLender's Name � z tandems Addonu U O I certify that 1 have read this application and state Nal the above information is Uy;"! colonel.l agree to comply wit all city and county onfinances and state lam miming to 8 tS.'J building convection,ant hereby auNadm representatives of this city to enter upon Nc rA ahovemcajuZEIMONS nedproperty forinspection purposes. Cis (Wo)agree to ave,indemnify and lump harmleas the City of Cupertino against roti rn liabilitim.luend axPcnaamit. mak in my my women against said City conagmling of Nis Permit. .. APPLI ANDS AND WILL COMPLY W ALL N-POINT Issued by: Date SO ofA —Re-roofs Dole HAZARDOUS MATERIALS DISCLOSURE Dam Type of Roof Will the applicant or future building occupunutore orhandle haardaus material az dented by the Cupenim Municipal Code.Chapter 9.13,and Ne Health and Safety Code.odYm Iy Section 25532(a)? 111Ne All roofs shall be inspected prior to any roofing material being installed. I If a roof is installed without first obtainingan ins ection,I agree to remove Will tht air contaminants or furore Wilding occupant sea ea Air Qu or devise which p g 't hvaMnm sir conuminenu as dcEned by this Bay Area Air Quality Management all new materials for inspection. vicR CYu %No I have revel the smawHalsmquimmmtsunder Chapter6.95oftheCslifor- nuHmith&SafetyC , cdom25505.25533md25534.lmdcauntlthalfthm Wilding doer not cu prely he tenant.that II u my responsibility to roti y des oce pant of me mqulm dwhlc thaWmetpdormiomnecofaCtmpcate Ibcups y Signature of Applicant Date 0 room agent f Date All roof coverings to be Class"B"or better O gOl Oolfj' Y CITY OF CUPERTINO TEMP POWER CUPEhTINO PERMIT APPLICATION FORM d� APN # 2 Z/ 22 — Z10 10 Date: I V W Building Address.. 10 1 a 5 A to-Lo; Av-e- , Owner's Name: Phone #: tZiC �� 25 �� ► � sKi ��08 � 36� - o(0-4- Contractor: Phone#: TSD Fax #: Contact: Phone #: c,k-, files-zYVASKi (sa,� •e.� Contractor License #: Cupertino Business License #: Job Description: Residential Commercial ❑ Valuation (cost of project): / e- Quantity Fee ID Fee Description Fee Group Permit Type IERT>1K Res. Temp Power>1K E 1REAP14 Amps 1 ERT<200 Res. Temp Power<200 E - Amps IERT2001K Res. Temp Power 200-1K E Amps IEPERMITFE Electric Permit Issuance E M IELCPLNCK Electric Plan Check E 1BSEISMICR Seismic Residential B ` Qo 1, � Y v �. � � 2L. �._. .__;, � �� . • • • � CITY OF CUPERTINO TEMP POWER 4OF .CUPERTINO PERMIT APPLICATION FORM Quantity Fee ID Fee Description Fee Group Permit Type IBSEISMICO Seismic Commercial B 10EAP14 IECT<200 Commercial Temp Power E <200 Amps IECT>1K Commercial Temp Power E >IKAm s IECT2001K Commercial Temp Power E 100-1K Amps / 1TRAVDOC Travel & Documentation B ( Fee 1BUSLIC Business License B CITY OF CUPERTINO is 4 ITEMS OF 4 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Blk: Lot: APN . . . . . . . . : 32622029 . 00 DATE ISSUED. . . . . . . : 01/09/2008 RECEIPT #. . . . . . . . . : BS000003653 REFERENCE ID # . . . : 08010048 SITE ADDRESS . . . . . : 10185 EMPIRE AVE SUBDIVISION . . . . . . . CITY . . . . . . . . . . . . . : CUPERTINO IMPACT AREA . . . . . . : OWNER . . . . . . . . . . . . : RICK BLESZYNSKI ADDRESS . . . . . . . . . . : 10185 EMPIRE AVE CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-1243 RECEIVED FROM . . . . : VIATCHESLAV KOMOV CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096 , COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED ADDRESS . . . . . . . . . . : CITY/STATE/ZIP . . . . TELEPHONE . . . . . . . . : • FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- ---------- ---------- ---------- ---------- 1BSEISMICR VALUATION 141. 00 0 .50 0. 00 0. 50 0. 00 1EPERMITFE FLAT RATE 1 . 00 40.79 0 . 00 40.79 0. 00 1ERT<200 UNITS 1. 00 40.79 0. 00 40 .79 0. 00 1TRAVDOC FLAT RATE 1. 00 40 .79 0. 00 40 .79 0. 00 TOTAL PERMIT 122 .87 0 . 00 122 . 87 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CREDIT CARD 122 . 87 VISA --------------- TOTAL RECEIPT 122 . 87 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -- ---------------------------- -------- -------------------- 402 TEMPORARY POWER Community Development 10300 Torre Avenue OT Cupertino CA 95014 Telephone(408)777-3228 F Fax(408)777-3333 rUPEKTINO Building De artment JOB ADDRESS: PERMIT# n G o �PJ� aZ 15 � 1Vt NO � i � 0�0 OWNER'S NAME: 2S zl� i PHONE oop GENERAL CONTRACTOR B-Wnl eR - FAX # I am not using any subcontractors: -'$b , t -2erp6 Signature Date Please check applicable subcontractors and complete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood a Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock i Tile C ntractor Signature ate