04090223 CITY OF CUPERTINO °"" "�' ` �
BUILDING DIVISION PER A C®NTItACTOR INFURMN:
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RUILDINGADDRESS: YULIA RUMALEAN 11111T"04090223
-79A r�ZiPT)FN IDI ArR CT
OWNER'S NAME: PERMIT ISSUE DATE
6-4EYU SANITARY C NTROL NO.
ARCHITECUEN'GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECIi
po 0 0 0
°00
LICENSED IOCOMRd anOR'SDECons of CON Job Deppscrl�Pnt'1O0fl yt\ p ��
w❑ ehcrcbyaffirm NallamftheBduromprovisionsofl Coda. ir 9(creeense I, gI Y61 Y�JII�/f,�pt\IL
;ib
withScene"IlllgBnf Division3nfshc Business and Pmfesxiuns CnJe.end mylicrnuis
'_o`H LmumClaand.«"'' WINDOW REPLAEMENT
D,y,? Lions.Chas Lica
—p
Data ty GrnlDECLARATION
MAR 9 2005
EARCHITECTS DECLARATION
rc 1 undcrsund my plans shall he used as public acords
0 U (ttttt�f�����qpppp
Licensed encs innal V U T A ®ry pr fl�,(��;
S
OWNER-BUILDER DECLARATION tNgb 8f 11[pttl��VNp @✓J
n Y 1 hereby.('fent that 1 1. exempt from the Pr Cantor,Cu a:An,c Law for themy
Kp O fallowing neon. er it t ]!131.5.Business and Profdemolli Code:Any city or i county
m w4,ich,.quires n permit In surer the aline improve,demolish,m repair any avucom
prior In its censed pursuant rto(be the applicant for such Permit icic esigned aummem
so-
that hcis encingsedtion7 hepmvivision3MComsinesiLiccnuhw(Chap¢ry Sq.Ft. Floor Area Valuation
�F p (commencing with Section and(ifthe
Division]of the Business. him.A sinus Cn�c)ter
that he is cxcmpl Ihrtofrom and she bmis for she alleged exemption.Any violminn of
Sermon 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 6'23 VO 0 Occupancy Type
not more Nan five hundred dollars($500).
❑I,as owner of the property,or my employee wish wage as their sole compensation,
will do do,work,and Ne structure is not intended oroffered for sale(Sir.70.4,Business
and Propositions Conic:The Contractor's Lice=Law dont not apply to an owner of Required Inspections
property whir builds or impmvu Thereon.and whodims such work himsaff or through his
wn employees,provided Iha such improvements arc not inumded oroRered for sale If,
however,the building or improvement is sold within one yea of completion,the ownca
Wilder
will have the burden of proving deal he did not build or improve fur puryau of
sale.).
❑1.az owner of Ne property,am inclusively contracting with licensed contractors to
cmuwa the project(Sec.71X4,Business and Prafmsioru Cade)The Canmcmri Li-
come Low dont not apply he an owner of property who builds or improve Ihcuon,and.
who contracts for such projects wish a contracmr(s)licensed pursuant an the Contractor's
License Law,
cx
cmptunder Scc,(^I' I II .B&PCfor thi mman
O nor ! 1 3I11'g0� Date
WORK T COMPENSATION DECLARATION
I hereby of oar under penally of perjury one of7rollp'wing declarations: -
1 have and will maintain a Cenifma orcommat to ul4inname for Workers Cumprn-
nation,as provided far by Section 3700 of the labor Code.for he pertormance of the
work for which this permit is issued.
❑I have and will maintain Wurkcr's Compensation Insurance,as Iaquired by Section
3700 of the labor Code,for Ne imformane,of she work for which this permit is issued.
My Workers Co.pensabad Insurance came,and Policy number are:
Cartier. Policy No.:
CERTIFICATEOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcompleted HIM permit is fm one hundieddallars($100)
or less.) '
1 terrify Na in the p.rronowas of the work for which this permit is issued,l shall oat
amid any{�oommanyon.7 snaztobecome sal Workers'Compeneum.
Laws of CaNfornia.Datc � 1'l�nu
Applicant"��T/
OTICE TO APPLICANT:If,m16,mbld4 this Cor ilicao of Exception,you should
cam.subject to th.Worker's Compensation provisions of me Lshm Code:you most
,J forthwith comply with such provisions or this permit shall he deemed evoked.
'Z OCONSfRUCrION LENDING AGENCY
.Iheohy a@rm
that dram is a construction lending agency for the performance of
ani No work fur which this permit is issued(Sea.3(y97,Civ.C.)
W Q Under's Name
z Lender's Address
zo)V Q 1 codify too 1 have read this application and auto that the above information is
la.F emrca 1 agree to comply with all city and county rainstorm and .to laws rotating to
0 V building construction.and hereby abndn<repressamarivice of this city to enter upon the
r W shove-mentioned property for inspecuon purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities.judgments,costs and expanses which may in any way accrue againstawd City
U in comcqucncc of the granting affair permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REqyyLATIO S.
G C/Ijlld(I �����IoU Re-roofs
Indoor of ApidintrUCionarctor Data
HAZARDOUS MATERIALS DISCLDSSU: Type of Roof
Will fire applicant or future building occupant stun or h nc h immoas.,,,do]
az corned by the Cupertino Municipal Codc,Chapter 9.11.and the Health and Safety
Cadr.Scedon25532oul All roofs shall be inspected prior to any roofing material being installed.
❑Yea 9N
Will thea applicant future building occupant use equipment ordcvias which If a roof is installed without first obtaining an inspection,I agree to remove
411 PP I pan aAirQn
it hazardous air contaminants az JcfncJ by the Bay Area Air Quality Management all new materials for inspection.
lisvip?
E]Yen KN.
1 have mad be W7,ardnus materials requirements under Chapter 6.95 of the Califon
ria Hcaith&SafctyCWi Sectors 25505.25533 soil M34.1 undcrsund Natrue Wilding
Join nor c ment"haw:a"Tran,Nat it is my mepomihility,to notify the occupant of the
mature. 1,,hchbwdI cn lfmmh,issa aoracrNfeaorO np ry. Signature of Applicant Date
)140 �T IOL All roof coverings to be Class "B" or better
0;2cr ailhm,ld ajml Dale
OVER-BUILDER VERIFICAT�N
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
• B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A _ All of the work
B. A portion of the work,(complete section below)
Contractor Address/City Phone # State License # Type of work to
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
® portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Inform�on(rev se side).
/y
Property Owner's Signature: ,(yL Date/
Job Address: W2,6 GaA6 W I etcL c-t . Pmt# a o 6 2Z
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.
City of Cupertino Building Department
CITY OF 10300 Torre Avenuf�
C U P E RT I N O Phone: (408)777-32�
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are tate responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing their own work If your work is being performed by someone other than yourself,you
may Protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is$200 or more for the entire pro)ect, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers compensation insurance,disability insurance costs,and unemployment compensation
contributions. •
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the US.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed contractor or
subcontractor,only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
•
Printed an Recycled Paper
CITY OF CUPERTINO* q
CITY OF PERMIT APPLICATION FORM c 2�
CUPEkTINO
N# Date: �
Building Ad ess: Mailing Address $i fer t b ilding address):
�. 20 j w Garden *Ica_ _a
Owner's Ne: Phone#:
gUIiG 4ma(ean
Contra ct: n� License #:
Contact: � 1 ',� Phone: y0� 9�G �G61 Cupertino Business License#:
`11ICG I�*ah Fax:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ❑ Wch ❑
Job Description: �J
Residential ❑ v " rci ❑
Sq.Ft. Floor Area: $/Sq. t.:
1
Cost of Project: �.� Occupancy Group:
Type of Construction: Please check the x if the project is a
second-story addition: ❑
ro'ect Size: Standard ❑ Large ❑ Major ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other Appliances MECHANICAL
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax BUILDING
BCONSTAX Ind/Off/Comm/ uasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Constax—Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elee Svcs 600V<=200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
1 of 3
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SEEP 111'11'70V
0-TY OF a Cy ,
t t 14LO r IRVG DEPARINiENT
<4,
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5 f
1 APPROVED
IW A66�RU W as TK CWQj
9Afi_
F thit set p enc tions MUST
the i times and it is un,
let M Yu maho any CM49N or alteration
sm without written
pemrission frees
The sWato8 of this pian and Vad imtioas
a ALl NOT.be held to pamdt or to he ar
3p 1 ria-0 n10'iailm ad my tri
4 Jim 04Y i9retanaaot®r um taw.
CITY OF CUPERTINO "^�'+ � �
BUILDING DIVISION PERMIT a�CONTRACTORINFORMATION
BUILDING ADDRESS: YULIA RUMALEAN PERMIT NO04090223
2072A (-ARD7NT PTAI22 CT
NEWS NAME: PERMIT EDAM
NE: SANITARY C OL NO.
ARCHITECT E GINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
u00
LICENSED CONTRACOR'SDECLARATION Job Description
V Ion 7 affirm that I am IittnseO under provisions of Chapter 9(commencingmhe.. in
n� wish SeI iereby a)urthatDivision 3ofthaednde and Professions nd 9cenciis
ea wt I.fall fomeaod effect WINDOW REPLAEMENT
j License Class Lk.0
F Dam contractor .J
ARCHITECTS DECLARATION v
1 unduhe
crsnJ my plans shall used ss public returns �?/
JyU
30� Licensed Professional
S OWNER-BUILDER DECLARATION
Y I herehy affirm Nat I am aempt from tht Contractors License law for the
o o (allowing mason.(Section 7031.5,Business and Professions Coda:Any city or county
which requires a permit w construct,alter,improve,demolish.or repair any stmcmro
'y tar
prior it)its issuance.also requires the apNiamfor such Permit to file a signed statement
that he is licensed pursuant to she provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuatlon
��c (commencing wish Section 7000)of Division 3 of Ne Business and Proressisel Cash)or
�" _ dot ha -exempt tomfrom and the baso for the alleged exemption.Any violation of
Section 7031.5 by arty applicant for a permit subjects Ne applicant so a civil Penalty of 3 591b$LS143e10 O Occupancy Type
not mom Nan five hundred dollars($500).
1,M owner arms progeny,or my employees with wages as their sole compensation,
will do the work,and the,stratum is not intended or offered for sale(Sec.7014,Hatundss
and Professions Cade:The Contractor's Liccme law docs WE apply to an owner of Required Inspections
pmpcnywho builcisorimpromatnueon,and who data suchworkhimself or through his
tun employees,provided shat such improvement are not intended or offered frowde.If,
however,she building or improvement is sold within one yew of completion,Ne owner-
Wildef will haw the burden of proving Nat he did not build or improve for purpose of
sale.).
C)h as owmr of the progeny,am Exclusively contracting with licsved canvassers to
comrma the project(Sec.7064.Business and Processions Code:)The Cantraemru Li
me law dors not apply to an owner of property who builds or improves themon,and
who contracts for such projects wit a contractor(s)licensed pursuant to the Contractors
License law.
exempt under PfoNis
��ILamQlDrt,l
ENSATIONDKLARATION
WI hereby ERrm under penalty of perjury one ofN all ing dalwationes:
❑1 have end will maintain a Cestifiewc of Convent m self-imum for Worker'sCompan-
sestion,as provided for by Section 3700 of the labor Code,for she Performance of the
work for which this permit is issued.
1 have and will maintain Warsaw's Compensation Insurance,as mquimd by Section
3700 of Nc Labar Code.for the performance niche work fur which this Permit is issued.
My Workch Comperuau m l...sante,and Polity number am:
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('Thu section need not necanplmed if dm Permit is for one hundred dollars($ip))
or lest)
1 unify shm in she perrurmanco of the work for which this permit is issued,1 shall nut
employ any octan any manner an u m becomem ' oth Workers'Cnmpcnsauon
Laws Y. It
Appliant
OTIC E TO APPLICANT:I.aft rteKing this Certificate of Exemption,you should
me subject to Ne Worker's Compensation provisions of Nt lahnr Code,you most
forthwith comply with such provisions or this Permit shall be deemed mwked.
zCONSTRUCTION LENDING AGENCY
[�. 1 hereby affirm Nat there is a conswninn lending a,Emy Tor due pcutatur we of
a tot work fur which Nis permit u issued(See 3097,Co.C.)
W Q Lenders Name
0. Landcr's Address
tU Q I comfy Nat I have Rad this application and sum Nat the above information Is
W P correct.1 agree to comply wish all city and county on inanRa and sum laws relating to
0U building construction.and hereby aushoncemprosenutiw.s of Nis city to enter upon dm
r W .how-mentioned property for im,paruon purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Iiabilides.judgments,costs and expenses which may in any way aceme against said City
Uz inemuequeneear the gustingcf Nis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Dale
SOURc R pl)AD s. Re-roofs
gnatum of ApplicanUContuctor Dam
HAZARDOUS MATERIALS DISCLType of Roof
Will the applicant or future building Occupant mre or hupqZcEmmaus material
as defined by the Cupertino Municipal Code.Chapter 9.13.end the Health and Safety
mk.
Section s zss3z(q? All roofs shall be inspected prior to an roofing material being Installed.
❑tionNa P P Y g g
Will Nc appliam or future building occupant use equipment or dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
emit naiarnme,air Watommons as defined by Ne Bay Ama Air Quality Management all new materials for inspection.
District?
❑Yes kNu
I have mad the lecardons male ialarequiremenu uncut Chapmr6.95 of the Califon
ma HeatO&Saccty Code.Swuaru25505.M533 and 25534.1 understand shwifdm Wilding
data note ndy haw a smart,thw it is my raporwhility m nasty me,recupam or the
requirem e n kcompsofutlssaanceoraccnl0c:mor apzncy. Signature of Applicant Date
}/0
era oat icdagem Dam All roof coverings to be Class"B"or better