04090057 CITY OF CUPERTINO - °""^" �^ a; �s. `•' """'''�
BUILDING DIVISION PERMIT k.C,ON TRAC-TORRINFORMAT„I'O��a
BUILDING ADDRESS: FATEKH VERGASOV PERMIT NO 04090057
21921 MCCLELLAN RD
OWNER'S NAME: PERMITISUEDATE
FATEKH VERGASOV 21921
E: SANITARY NO. - CONTROL N0.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u 0 o LICENSED CONTRACTOR'S DECLARATION O O O O
YmF I hemby affirm Net I am licemcd under provisions of Chapter 9(Commencing Job Description
SZwith Section 7")of Division 3 of NC Business and Professions Code.and my license is _--
__�h inrtumre amderr« RELOCATE GAS & ELECT. METER
yj i License Class Lk.Is
n-W Dale Contractor
J ARCHIEC1'S DECLARATION
zy 1 undersand in,plans hell he..it as public nccnrd.
DyJ
o
Licensed Professional '- p p p
@ g OWNER-BUILDER DECLARATION 'pV■���peL
4<y I bunchy affirm that I am exempt from Me,Contractors License Law for
E a 0 following mason.(Sown 7031.5,Business and Professions Code:Any city or Cou
m which requires a permit to Construct alter,improve,demolish,or repair any structure a �p
prior he hs is issuenec.alsu requires thea,pli,mit I...ch permiuo file.signed statement '/ 0 LBYJ
< that is housed pI..,to the provisionsnf the Corrosion',U..Law(Chapter 9 — t. Floor Area Valuation
z�g (commencing with Section 7l )of Division Sof NC Business and PmfesionsCMc)or
'��.- Nat he is exempt therefman and Ne basis for the alleged exemption.Any Added on of
Section 7031.5 by any applicant for a permit subjees Ne applicant to a civil ULD1WGro 0
nor mom Nan five hundred delta.05W). pc Occupancy Type
1,as owns of Ne property,err mY emplaycea with wage as dsir sole can
will do the work,end Nc."Cusec i.not intended oro@red ulasi a(Sac.lOsa,toomess
and Prof¢siom Cade:The Contractors License Law does oat apply to an owner of - - Required Inspections
properywho builds orimprows Herron,and whodoessuch wort himself orshrough his
Own employcea,provided dmuuch improsements me not intended oroRered formic.If. _
howcvcr,toe building or improvement is sold within one year of completion.Ne owner-
builder will have the burden of proving that he did not Wild or improve for purpose of
❑1.as Owner of the property,em exclusive] contracting with licensed wnvacmrs to
construct the project(See.load,Busineu Profusuaasde:)Calis Conoxctor't U.
cense law dors not apply to an her
er of p ny who builds or improaee daemon,and
who contracts for such projects w' seem Cor($)licensed purmanl in Ne Contractor's
Licence Law.
til am exempt under Sec. ,B&PC for Met reason
Own Das It?-06-0�7
WOR E PENSATION ATION
I hereby eflimt salty of perjury one or the following declarations:
I have and will main erdficare of cement teself-insu ,for WorkersCompen-
sation,as provided for by Section 3100 of Ne Labor Code.for Ne performance of Ne
work for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance,as required by Section
3700 of Ne labor Code.for Ne performance of the work for which this permit is issued.
My Worker's Compensation Instance easier and Policy number am:
Caller: Polity No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu senior need not M completed if de permit is formic hundred dollars(SIM)
or loss.)
1 certify Net in the Performance of the work for which Nu permit u issued,l shall not
employ any person in any manner so as to become subject o the WorkersCompensation
Laws of Califomia Date
Applicant
NOTICE TO APPLICANT:If,after making this Cedificare of Exemption.you should
become subject to the Wohers Compensation previsions of Ne IaMr Code,you most
.J mz forthwith Comply with such provision or his permit shall be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
[r I hnehy afrire Nat Hex is a construction lending agency for Me performance of
E
dao work fur which this pencil is issued(Sec.3(19?.Civ,C.)
CQ Underi Name
z tender's Address
U Q 1 certify that I have rex this application and sato Nal Meand
shove Cos misting u
F carrcn.I agree to comply wi all city and mussy medwS Of and sou laws r upon t to
0 building constm ion.mdh by auNoum rtprescnusives of this City to enter upon Nc
U D.1 in coescipue n property impe is purposes
t--i a. (Wc). to save ndcmnify and keep harmless the City of Caperton ap.ins,
CO liabilitieA jud memcco. and expenses which may in any way accrue against mid City
C..3 z in conseque of Ne Lingo ms pcmmit,
APPLIC
UNo I ST AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
Re-roofs
amt pprcanUConeactor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
it Ne applicant or future building mcupro"mre or handle hvudtus material
dcfm it y IN,Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
ale, Yes 25532(.)? All All roofs shall be inspected prior to any roofing material being installed.
Will the applicant of mime building o eupmt use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
sit hamdous air conumimnexasdefined by the Bay Arca Air Quality Management all new materials for inspection.
Dissiet?
❑Yes ®Nu
[have addacha rdnusmawHalsmquimmenuundcr Chapmr6.95ofNcCalifor-
niaHOalth& afctyC .kc =25505.25533an025534.iunkn dNmifdc building
dors not c on h a tenant,Nu it k my Msponsibility to maul'y Ne aculum of the
myuincm mu poor to issuance oface fiewofOcmpancy. Signature of Applicant Date
Iver oriaedage.t Date All roof coverings to be Class "B"or better