04040049 c=Or CUPEaTmO CON CRACTQR INS C1RMATION '
BUILDING DIVISION PERMIT asy, pip( yA_p x 61R '
BUILDING ADDRESS: PERMIT NO.
KOBETSKY CONSTRUCTION 04040049
PERMIT LSSUH DATE
ER'S NAME:
SANITARY O OL N0.
ONE:JACK F, TRIST-T TAYT,np R42 R112TR TDR.
BUILDING PERMIT INFO
ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION Job Description= f�
1 hearty efrom that I®n licensed under provisions of Chapter 9(commencing ��I I`\I] �i.� (� 2 D
with SradmI700B.fDivision Sof the Busmes and Prufcssiom Code,end myliccnsc is U S7(r—\!�{,_
o inmrr , derfeet. /gyp Licens _ ' MS BATHRM REMODEL
E"o Date Cunrect.rJUN 2
_ 2004
ATION
y a I understand my pl ns hall)he used 00 ic rccold,
;al;; Licensed Professional ��0���@��
S OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from Ne Contractor's License Law for the
HC following o .,(Sermon 703 I.S.Business and Professions Code:Any city m county
which acquires a permit to construct,alter,improve,demolish,or repair any stmcture
FIy poor mats issuance,also requires the applicant for such pentium file a signed statement Valu ti n
eee
a that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq. Ft.Floor Area
(commencing with Sediun](1[1BI of DivisionJOf the Business and Professions Cndc7ur
i Net he is exempt themfrom and the basis far the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil Penalty of 3AT419'�Ip*r00 Occupancy Type
not more than five hundred dollars(E50E.
rl 1,as Owner of the prep bly,or my employees with wages as their sole compensation,
will do the work and the spucture is not imended or offered far sale(Sao 7044,Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of q P
property who builds or improves thereon,and whodmasuch work himself or through his
own employees,provided that such improvements are not intended oroRcred for sale.If.
however,the building or improvement is sold within one year of completion.to mxamr
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
E]1,as owner of the property,am exclusively contracting with licensed contractors to
construct the pmjeet(Sec.70,14.Business and Professions Code:)The Couracters U.
cents law does not apply to an owner of progeny who builds or improves thereon,and
wpm contracts for such projects with a consumerist licensed pursuant no the Compactor's
License Law.
❑I am exempt under See. ,B&PC for this moon
137MerDate
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declaration:
have and will maintain a Certifica¢of Consent to self-insure for Warkcr's Compen-
sation,
Ompem
n,as provided for by Section 3700 of the labor Code,for the performance of Ne
for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as required by Section
of the Labe,Code,for the performance of Ree work for which this permit is issued.
oak Pens ioml u coc.noernd Paliry�omberve:
/ ERTIFICATEO/ EM Pa OM WORKERS'
COMPENSATION INSURANCE
('Inas accord need not he completed Ethe Permit Is forma,hundred dollars(5101)
or If...)
I cenify that in the performance of the work for which this permit is issued,1 shall not
em Ploy any pars min any n Oasmbccamesubjmvnthe Wcomi Compensation
laws.(Cali D
A not.
/
NOTI O APPLICANT:If,after makipgrthis Cenifica¢of Exemption,you should
b object to the Worker's Compensation provisions of the Labor Code,you must
OZ forthwith comply with such provisions Or this Permit shall be deemed manked.
z CONSTRUCTION LENDING AGENCY
E.. 1 hereby affirm Nat dere is a construction lending agency lar the performance of
ly' 7 the work fur which Reis permit is issued(Sec.3197,Civ.C.)
Lg1 A Lender's Name
IY Lender's Address
U 0 1 cenify Net 1 have read this application and stain Real the above information is
DL correct.1 agree to comply with all city and county ordinances and spite laws relating to
OV building construction,and hereby authanae representatoma of this city to enter upon the
U above mentioned propeny for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
to liehilitics,judgmcnts,casts antl expenses which may in any way accmc against saiO City
C)tZin-t
APPLICANT eUNDERSTANDS AND WILL COMPLY WITH ALL NON-PgINT Issued by: Dat
SOU CER ULATI NS s
— Re-roofs
5 of Applicam/Cmanscmr D
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant or future building Occupant store or handle humerus mamdal
as defined by the Cupenion Municipal Code,Chapter 9.12,and the Health and Safety
Affhoo.Section 25532(.)? � All roofs shall be inspected prior to any roofing material being installed.
❑Yes E Nu
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
n h.eardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
vole'?
❑Yes [nNo
I have read be incautious materials requirements under Chapter 6.95 of the Califor-
nia Heald&Safety Code.Sections 25585,25533 and 25534.1 understand that ifthe building
does not currently have a tenant Nat it is my responsibility m nod I the occupant of do
mquimorou hmhmist b,met tiro' aaneemraCerdrea¢mrOcempan . Signature of Applicant Date
w atnmrizedagent Date All roof coverings to be Class"B" or better