02020009 CITY
DSIONO
IVIiSiNPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21695 NOONAN CT CUPERTINO PLUMBING �u 02020009
OWNER'S NAME:
YAAKOV MICSTRIN 10297 S DE ANZA BLV AgPy�IcPbo�S)�8"U2
PHONE: SAANDAARY NOCONTROL
U tJ CONTROL NO.
(408) 253-0618
MP+OO ARCHITEC-VENGINEER: BUILDING PERMIT INFO
be u BLDG ELECT PLUMB MECH
baa LJL-J L=l c=1
LICENSED CONTRACTOR'S DECLARATION
z 5 y Job Description
OEl-C IhonW WWI of
thatln3of1helicensDa,iner provisions orr,Code,
(commencing REPIPE WATER SERVICE .
F=^tu with 5<ai.n](NM))nf Division].Rhe Business and Professions Code,and my license
zY ; is in full force and t
ec`z< License Class `� Lic.p Z 0
n U Dae ec C...or.,
—1.editisf)
t+tn - - ARCHITECT'S DECLARATI N
F
u0 S 1 an emmm y plans shall be used as public records
f�o
w a p O Licensed Professional
OWNER-BUILDER DECLARATION
u� I hereby affirm that 1 am exempt from the Contractor's License Law for the
t z< following reason.(Section 7031.5.Business and Profession.Coate:Any city or county, $3000
E o o which rcquims a permit to conswct,alter,improve,demolish,or repair my swcture
i3
positions isamice.as.rectums dc applicant in...ch pcmnnt file signed ar¢mom .-
thiat Imn,firroold pure h imth p roof the Contractors License L (Chapter9 .YH1'JIJI�[ A VaIIIaIIOn
(commencing: thSectn]000)ofD'1son3oftheBmne;adPofess Code) tiyl'l' .tt.`ltx':'I�.1Y. `sy'` "
or that be exempt therefrom and the bass for the.]tried'esempogd.Any violation
ofSection 9031.5 by any applicant for apermit subjects the applicant o a civil pcnaltp 106A $4]Ri$R & WATER I ' ' Occupancy YP
of nut more than live hundred dollars($500. P-N Occu ane Type
❑Lasowner.fthe propsmi myemployeea with wagers,their sole compensation. 202 _ - UNDERFLOOR PL MBING
. the work,and the structure is not intended or offered for sale(Sec.G09q: -'----" - _ "---'--- - - - .
° 301 - ROUGH PII2�2PUblLnspectionst
Business and Professions builds
o int Contractor's License o does such
does not apply m an
owner 302 - TUB & OR SHOWER
r through his awn employees, building
that such imprmt is sols within
not one you or
completion,dro;:the. Winer-builder isromwididndereabr 502 - FINAL-PLUMBING ENERGY.
provoosurpose of sale.)
will have the burden df proving that he did not buil]or 506 - GAS TEST
imp purpose
507- FINAL-PLUMBING—
I - -
r -
`El 1. vow fproperty. 1 ly contracting withlicensed commarmouran,
conswct the Project(Sec.]WBusiness and[-,of esst s Codc:)The C tmLic La d es poly t owner f property who ilds mpn <s thereon,
andwho contracts fa such pmjttm with a combartons)licensed purrourat.to ft.
Consomme,License Irl G/
D son intent,more,Sec B&P C fire,ho mason
Owner Dae C�j
- WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty.)linrjury mac of the following declarations.
❑ I have and will maintain a Certificate of Consent to'self-insure for Worker's �l
s\ Compensation, as provided for by Section 3700 of the Wbor Cade, for the
performuncc bf the work for which this pcm t is Issued: „
0.1 have and will maintain Wbrku's Cmrihmi cion Irradiation,as required by Sectmin
3]00.1 the Labor Cole,for the performance of the work for which Nis permit is
WorkceS npc a t 1 sur ier,and Policy umber are:
pal YN 713D� _sass..
issued M ono' i 1 / T
Cemi r .(t C RTIFlCATION OF EXEMPTION FROM1f. O R.S'l- )sip l
_ COMPENSATION INSURANCE
. .(Tbts'senion rase]not be cam .. ..... .......... sass.._ _____._......._... .. _.. .---sass__.\'
' dctad if the permit is for one hundred dollars
IS 100)or to,
sis
of
I certify B any per n in annex tofor beco'which thispermitis Worco l
Comnot employ am person in any man- t.bemm subject t the W.rkcri
Cooripcnwtion Laws of Calil.mia.Dam
.......... .. _... ._. ..._. _sass ._ sass
NO TICE TO APPLICANT.II;olmr mnking)his C<rtiticme of Eicmpnom,you should
became mbject m the Workers Compbnsaion provisions of the Labor Code,you must
CC fonhw'ithcomply with such provisions or this permit shall be dmm<d revoker.
Z tti
E•e-� "1 t CONSTRUCTION LENDING AGENCY
FCmt 1 hereby ifitm that thereis a c nswci un I nding agency fo the pcdm
mancc
of the work for which this pet rat issued(See.309],Civ.C.)
Q
6. Lender's Name- u...
. D.Z Lender's Address ... , . ,.
V 1 minify that I have read this application and amm that the above information is
Lz. Est correct.I agree to comply with all city end county ordinances and state laws mining
C).V rebuilding connriiction.and hereby nommize'represemaives ofthis city rat enter mom
the above-mentioned property for inspection purposes.. .__..
E„ y• (We)Sgrccs.save,indemnify and keep harmlesitho City orcu'pcnino against
V1 liabilities judgment,. o.t,and expendwhich may in any w., cmc g in t xaod
Z City. -q d[t g g nl th pe l �'. rate �.
NDfRST SNDS A'JD WILL COtIVLY,N'ITH ALL NbN'POiNT iISSUed by
2 ��7� i .
sig Appl c, tIC t Re-roofs
AR OUSMATERIALS ISCLOSURE , e
'boll she apple nwr(t mbiildmg ottupant.mre.r haomle hazardous mu<ri I . ...Typo Of Roof.. ._ �_.._.._ - .-.. . ... ... ..
as
Crn(ISabont2.53Cupenino Municipal Cad Chapter 913,and the H Ith and Safety n,\ 1' -: ,s'�r`o-s. 't• s ) ., ,t,•v , � ','.
'0Ye. 2,a) .o' r ,'`.l..i.u.l. rJ .i i+. l
.. ,. . : .....All roofs shall be,mspected prior-to.,any roofing material being installed.
Will the ppl' mo f t b itdingoccupamuscq p morJe ices which If a roof is installedlwithout first obtaining an inspection; I agree.to'remove
em t i deal a r mnmm nares de Ii d by the Bay Arend Quality Management
Di.t'et - _ all new materials for inspection. Applicant understands and will comply with
- ❑Ter No' - - all non-pointsouice regulations. .
t 'I havetrcad the hamrdous materials requircm ents under Chapter 6.95 of the
if.he uia Hcahh&Safny Code,Swims 25505, it
and 25534,(understand that
if.he Nm it is my responsibility to notify she -
of the rSqui mem hick must be met prior m issuance of n Confute of
«u, 'y Signature of Applicant Date
i
:. _. .. . . .. _ sass. .---..._.. . . sass
Owner or amho'W ager DateAll roof coverings to be Class `B" or better
-OFFICE
. .r . ..,. . ..