06060195 CITY OF CUPERTINOs�
BUILDING DIVISION
PERMIT .-Cd�1'$TRACTC/R INl`'1RMA '�,QN
B
UILDING ADDRESS: NICK KLEDZ IK PERMIT No.06060195
10500 SAN FELIPE RD
OW NER'S NAME: PERMIT ISSUE DATE
NICK KLEDZIK 06/22/2006
NE: SANITARY NO. CONTROL NO.
ARCHIIECTIENGINEER: BUILDING PERMITINFO
0 0 ELECT �t� 0
186
LICENSED coNlRAC DRS DecuganoN Job Description
yFF I hereby affirm that I w Russell under provisions of Chapter 9(commencing
S with Section 701h2)of Division 3 of the Business and Profettloas Code,and my licenses
n' y infullfamalndeffect. KITCHEN AND MASTERBATH REMODEL, MINOR STRUCTURA
j$tE Lic..Clan Lk.N
CC o Due Contraction
G ARCHITECTS DECLARATION
�t 1 understand my plans Nall he used an public records
Licensed Pmfessianal
^
OWNER-BUILDER DECLARATION
4 i I hereby Siloam that I am exempt[rum the Conmaetors License Law for the
following=.a.(Section 7031.5,Business and Profevtiom Cade:My city or county
which requires a permit an construct,alter,improve,demolish.or repair any Structure $55000
prior to its issuance,also require,the applicant for such Pcmil 10 file asigned statement Valuation
< that W is licensed pursuant to the provisions of the Controcan's License law(Chapter 9 Sq.Ft. Floor Area
E 3 (commencing with Section 7000)at Division Sat dte BuSSUSS and Profusions Code)w
that he is buts for the
leged
ola on of
— Section 7031 5 by any applicant ffrom add ar a permit Subjects Ne applicant to a civilipenalty of
not more than five hundred dollars($500). ET Occupancy Type
n
❑I,u owner-(the property,a my mmployct with wags u thew sale compensation.
andothe worrsand theah Ocanuis mmesLicendwaRertdfanale(Ace.7aM,Busmen Required Inspections
end Professions Cade:The CanussmrS L.kate law dos but apply tr an owner of q P
own enywho Wildsorlmprovu ther prove who are,
not work orroffredthrough his
awn employers,prided that ouch Improvements wit arc not toOfintended aroaertd for nte.IL
builder.the building or improvement s mid within can yearw completion the owrcr-
builder MII vise the burden of proving thathe nisi not build or Improve far tomo¢of
,as awnor of due Meant.am esclaslvely communing wit licensed mnuctuo an
LONImeI NC pmjm is".7BOC.BLLVaeai and RafenLON Cade:)Ile Contravenes U.
ave Law dose not apply to an awns of Property who builds or Improves Nemo,and,
who contracts far such projects MN acantraawrtU licensed Pursuant to ft Committees
Licdnee law.
ow.areesdmm net Date PCfar this ruwn
WORKER'S COMPENSATION DECLARATION
I hereby star under puWty of perjury rn of the following dedamdm
1 hew and Dail[maintain a CrsuOtte mm of Caesars self-Intere fu Wad¢hCompm-
radon,u pmvidcd far by Section 3700 of the labor Code.for the perfarmutce Of the
work for which this pmalt is hued.
D 1 have and will maintain Waasses Compensation[assurance,as tequred by Section
3700 of the Labor Cade,for the pefformana of the work forwhich this permit IS issued
My Warkefs Computation Insuratee artier and Policy number art:
Cartier. Paltry No.:
CERTIFICATE OF PXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
('ms sccdon need mor he completed If ds permit it forum hundred dollars($100)
or leas.)
I certify that in the parfmmane.of the work for which this permit is usued.l shall nos
employ any person in any mennes"ubt:eomb too slr�Worken'Compemadon
Laws of California.D 1
Appliance
NOTICE TO APPLICANT.If,Mar making this Certificate of Eacmptian,you should
become subject in the Workers Compensation provisions of the Labor Code,you mut
,J O faMwish comply with Such provisions ver thin permit Shall be daemon raked.
Za y CONSTRUCTION LENDING AGENCY
[� I hereby amrm that them is a crossuerimh lending agency for the Performance;of
IY > the work far which this Permit is meed(sea.309'7,CN.ea
W�G Larsen Num,
z Larders Address
UR I certify that I hale rad this application and sum that the above information s
U.1- correct.I agree to comply with all city and county orlinatm and sus sec.114ng m
DU Wilding construction,and herby authorise rtpresemativr of this city to cnterupnn the
W above-mentioned preterit for inspection purposes-
(We)agrtd to save,indemnify and keep harmlos Orc City of Cupertino against
F"0 Iiahili4u,judgmuns,costa uM expense which may in any way accrue,against Said City /
U Z in eumequetrce of the trotting Of this permit. 6 ^I
h-•� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date L
SOURCE R O A NS 2
Re-roofs
Signume of Appliwal/Comraemr Date Type Of Roof
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building aecupmtsmre or handle hatndou munial
as defined by the Calamine Municipal Code,Chapter 9.12.and circ Health and Safety
Code,Section 25532(-)? All roofs shall be inspected prior to any roofing material being installed.
Dyes zstr
Will the applicant or fumre Wilding occupant sex equipment or clarions which If a roof is installed without first obtaining an inspection,I agree to remove
mit haurdnus air mnuminans u dcflncd by site Bay Ara Air Quality Management all new materials for inspection.
District?
OYu Mills
1 here mad the hua d.rowels requlremcns under Chapter 6.95 ofd eC-Ilbr
me Health&Safety Coda,ScNom 25505.25533 and 25534.l understood that lithe Wilding
does not currently have a senate.that It u my Impassability in notify the cecupent of the
aqui 77M--P Inissuance anCertificate ofoccupancy. — Signature of Applicant Date
Owner or authmiuda antsDas All roof coverings to be Class nBn or better