05120103 CITY OF CUPERTINOa <' -s�s ,a€ `atan*x`>« ,' "rash' '
BUILDING DIVISION PERMIT kCON'�RA0TQR� NFO flAT� jffi
BUILDING ADDRESS: ED V CONSTRUCTION PERMITN0.05120103
ER'S NAME: PERMIT ISSUE DATE
POMAR KRUSKOFF 4436 ROSCOMMON WAY 12/16/2005
NE: SANITARY NO, CONTROL NO.
(408) 898-0113
ARCHITECT(ENGINEER: BUILDING PERMIT INFO
BO EO PLO O
30o LICENSEDCONIRdunderSDEConsofCON JobDescription
i��j I thereby r cu' that 1 am f he Bu under provisions of,Coder 9(commencingis
wish SecOon 7IXIU)afDlvision J of the Business sod Professluv Code.and my license is
An mmufarm andeffc 55 2 ADD MS BATH IN (E) FL.
D J� License Clus Lle.
Data Contractor A—p r/ Ca VC'>10
ARCNTTECTSD public ecou
Y ION
1 undcrwad my ptm aNll M stud u public rocnrtla
J
hQ Llecnud Pvfessional
OWNEm exempt
DER DECLARATION
reason.
.(firm
that I em exempt tram the Conion;Co License Law for Ne
Coo (allowingulm,, (anion co 13.Business and Plnfsen Cad,:Any city or county �/"U
S S which requires a permit re construct,eller,Mprow,h per i t is nr e a sig any statement
_ Sec pdormslicen issuance.licensed pursuant
to the provisions,
of for such permit File LadChaperm
ggg < shalheialiccnudPunuanttnthe provislonsnflheCamrmmriLianu6w(Chapmr9 Sq.Ft. Floor Area gNValu n
o (commencing wish Section 70D0)of Division J or the Businmand Professions Cade)or a
3 flat be
is tberUrom and the basis for the alleged exemption Any violation of ft
Section 7031.5 byany applicant for w
a permit subjects the applicant be a ci0I penally of
not mart Nan 0w hundmd dollars(5300). T CCnUpanCy Type
❑I.u owner of the property,or my employees with wages u their ale compemadon, K
will do the work,and the swcture is not intended or arrested for awe(Sec.70".BusinessRaired Inspections
and Professions Code:The Co si utaes License Law does trot apply m an ou nrr e ns of q P
pmpmy wM builds or improwa thereon,and who don such workhimself or through bls
own employees,provided that such improvements art net Instructed"afraid fasate.if.
however,the building or improvement is mid within ane year of completion.the owner.
builder will haw she burden of proving that he did not build or improve for purpose of
ale.).
❑1,as mvocr of the property,am eselusiwly contracting with licensed contramas to
comment 09 project(Sec.7044,Business and Professiaa Code:)The Cantonese,Li.
serum Law doses not apply m an owner of NoWnywhe builtls or improv theuon,and
who contracts for such projects with a contocmr(s)Hamad pursuant in she Convector's
License Law.
❑1 erlr exempt under See. .B At P C fm this reason
Date-
WORKER'S
aoWORKER'S COMPENSATION DECLARATION
t I hereby affirm under Nulty of perjury aro of ft fallowing declvalions:
I haw and will maintain aCWfiau of Coveum ulFiuum fa Worker's Compere
sedan,u providrA f=by Session 37x0 of the Lahr Cade,fns the performance of she
work for which this pewit is issued.
❑1 bane and will maintain Workees Computation resonances,as required by Section
3700 of the laborCdc,for the performance of she wort for which this permit is loud.
My Worktes Comijignsation Inaunna artier and Policy number m:
Carrico Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mils section need not he completed if th pewit Is for au hundred&It=f$IM)
or less.)
1 certify Not in the performance of de work for which this Permit is imd.I shall not
,.play any penin in any manner esu Mb,mm Ito sieworkere Compensation
Laws of Califomly,patl
Applicant ( -�
NOTICE TO APPLICANT:If,after making this Oenificam of Efamption.you should
became Subject to she WorYees Compensation provisions of the labs Code,you most
.'O forthwith comply wish such provisions or this permitshall be deemed revoked.
y CONSTRUCTION LENDING AGENCY
[—i IMroby affirm that them Is a construction lending agcmY for the Performance of
a she work for which this permh 4 issued(Sec.3197,Civ.C.)
0.Q Lemims Name ,
0.z Lender's Address
J0 1 ceni(y that I haw read this application and nate that the alhw information Is
ly F town 1 ague to comply with all city and county ordinances and state laws relating to
U building construction.and hereby man rim uPrtsentatiwa of this city Is enter upon she
ITt aMve'menMocd property for Inspection pugrosea
�"•�LL (We)agree to sew,indemnify aad keep harmless the City of Cupertino against
o-y,on liabilities,Judgments,cuts and expenses which may in any my we=against said City
in
APPLICANT Uof ft Nranting of DERSTANDS ANTUN STANDS AWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
Re-roofs
Signuumof Appliam/Commmo' ` Dam
HAZARDOUS MATE61ALS DISCLOSURE Type of Roof
Will she applicant or future building occupantwre orhandle hoards"material
u dcrtud by the Cupertino Municipal Code.Chapter 9.13.and she Health and Safety
.Stdoesss3za)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes RI Na
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
i it harardaus air contaminants as dewed by she Bay Area Air Quality Management all new materials for inspection.
J iWic17
❑Yes XNu
I have read she summers materials requirements under Chapter 6.95 afthe Califon
.I,Heal&SsfmyCodc,sections 2SM5,35533 um115534.1 udcmand Nn If she Wilding
does tont currently hew a anent,dal k t my responsibility m rosily the occuput or the
require onto m p' r uctaneenire.marOcapermy. Signature of Applicant -Date
�d /2
Owner or authorimd ascnl Dow
oS All roof coverings to be Class"B" or better