05110079CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO -05110079
10472 LOCKWOOD DR
NER'S NAME:
PERMIT ISSUE DATE
DMITRY YUSUPOV & YELENA NA
MRE
006
NE:
SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
1 thereby &Mrm that 1 an licensed under provisions of Chapter 9 (Commencing
with Section 700D) of Division 3 of the Businem and Professions Code, and my licence u
mf.111menmd.ffeer.
ADDITION/REMODEL 6481-STUDY/KITCHEN/LAUNDRY
Clan k•g
LmLic.itContractor Dam
MASTERBEDRM/BATHRM (1ST & 2ND FLRS)
ARCHITECT'S DECLARATION
I understand my plans shall W used at public records
Licensed Professional
OWNER -BUILDER DECLARATION
I herehy alarm that 1 am exempt from the Cortnetors License Law far the
following rum.. (Section 7O3I.S, But. and Prefesdmu Cade: Any city or county
.
which myuirrs a permit to contract alter, improve, demolLM. nr rtput, any animus
Prior m its issuance. also requires the applicant for such permit o rile a signed Comment
that W is licensed purauamro tins provisions of the ConuacuR's Liam Law(Clopm 9
Sq. Ft. Floor Area
ValGblH911
(commencing with Sutton 7000) of Division J of On Business and Professions Code) or
that he Is exempt thnufrom and she basis far the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by Cory applicant fu a permit subjects she applicant to a civil penalty of
Out mea than me hundred dollars (M).
34229011.00
❑ 1, M owner of the property, Or my employees with warn as Neo min emnpewtian,
Required Inspections
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will do she work, and the structure Is not intended or offered for wc(Sec. 70/4, Business
Cade: The Ccuw, daces m Licanund wha dace Oates tet apply lf an owms is
and Proproperty who oesauhwmk hir ughWe ms
ertywhoss, ldspro
thimpt
�� Cw
ided tavu
offeor red for
own employees, provided that lmDrowmenu au not Intended aroffeud Toole. if.
own womenu
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however, the building u improvement Is sold within one year of Completion, Ne owner.
A7//{R-�j6pt9Y
Wilder will law the burden of proving Nn he did not build or Improw for purpose of
,lale.).
Qr I, at owner of the property, am exclusively contracting with licensed mnoenon to
V!9',ry L7 Lpa
Construct the project (Sec.Business4. Business and Proressiam Cade:) The, ConoamrC LI-
1 yr
cense law doer not apply to an owner of property who Wilds or improves Neuron. and,
who Cones for such projeaa with amnua ter(s) licensed pursuant in the ConuacmrC
Lleeuae law.
mexewnptund�See. .88PC(os aressoDau 06W
BR'S COMPENSATION DECLARATION
1 hereby &Man under Penally of perjury ane of the following declarationshave
and will maintain a CeiOua a( Content to self -imam far Wodrers Compen-
IMy
, an provided her by Salton 3700 al the labor Code, for Ne performance of Ne
for which Nis permit is laud.
haw and wilt maintain Waker's Compensation Insurance, u required by Section
of Ne UWr Code, far Ne performance ofthe work for which Nu permit is Weed.
Warkefs Compensation bmmnce artier and Policy number au:
Cartier. Policy No,:
CER 1FICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Tho union need Out W Compleu l if the Permit a fmonc hundred dollars ($100)
or leu.)
1 certify that in the performance of the work for which NIC permit is issued, I shall not
employ my person Inset, 0 ro W mesobjecs mthe Workers Competadon
La cer of California.n. C
Applies., 4d
NOTICE TO APPLICANT. If, Met making this Geainesm of Exemption, you should
income subject to the Worker's Compensation provisions of the labor Codn you mute
forthwith Comply with such provisiom or this Permit Call W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a mmuuctinn lending agenry for tie Performance of
Me wish fm which tiffs Permit Is bound! (See. 3097, Civ. C.)
'
Lenders Name
Leaders Address
1 ttnify that 1 haw red this application and sum Na the Move information IC
Corrett 1 agree at comply with all city and county ordinances and We laws relating m
building construction, and hereby aurban= representatives of this city to entre upon the
abow-memtiond Property for imPeetian Pugmses
(We) ague an save, Indemnify and kap har mlea the City of Cupertino against
liabilities,judgmmu. Casa and expenses which may In anyway memo ISCULaid City
in consequence of the gtmling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WI ALL NON -POINT
Issued by: Date 71 Z'U
SOU EGULATIONS.
QQ.0
Re -roofs
has Q fiI-+' 2/2 Db
Signmuu of IimVConumta Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will tie applicant or future Wilding occupant some uhaadle ltaurdom material
a round by the Cupertino Municipal Code. Chapter 9.12. and the Hcalth and Safety
ads, Section 25732(a)7
❑Yet
All roofs shall be inspected prior to an roofing material beim Installed.
P P Y 8 g
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant sic equipment or devices which
It handout ter contaminants a dcMod by the Bay Amo Air Quality Management
all new materials for inspection.
District?
❑ Yes 99. -
I have read the hatudruC maeAabuquirtmenu under Chapmr6.93 orthe Califor-
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naHoalNkSafctyCoh.SeNons 257(15.25337 un12753/.l undeaatd thatifdm Wilding
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doea not currently have a mount, that It a my responsibility to notify the occupant of the
o of aawhiehmamhe tpmiar muuan"or.Cutine. ser pane,
Sit(Obgnature of Applicant Date
All roof coverings to be Class "B" or better
Owner m,horiv agent Date
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