03070121 CITY OF CUPERTINO +C=Hsr:�xa�3r?a�5-'a" �",,:>� x
BUILDING DIVISION PERMIT > CONTE CTOR'INFORMATION
BuI LDING ADDRESS: BALDE MARINKO AND LAURA M PERMITN'03070121
E ' AM T-EVEDISRE) PERMIT ISSUE DATE
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION
at I thereby affirm that 1 am licensed under provisions of Chapter 9(Commencing Job Description
n< with Section]Of))of Division]afthe Business and Professions Cade,and my license is
cain full trimesteraffect.
-q'z License Class tic.« SERER & STORM DRAIN
::I
Dau: Contractor
£t:£ ARCHITECTS DECLARATION
1 understand my plans&hall be used n public records
DyU
C Licensed Professional
OWNER-BUILDER DECLARATION (J-
F I hereby affirm that I am exempt from the Contractor's License Law for the [\•l7
00 following mason.(Section 83I.5.Businessand Professinu CWT:Any city or County
$(Li which m0eiru a permit m cmnatruct,alma improve,demolish,or repair any structure
H Il^ prions its issuance,also equiea the Applicant for such Permit o file a signed statement
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area Valuation
CFS (commencing with Section 70f11)mf Division J oldie Business and Profusions Code)or
that he Is exempt tbemfmm and the be¢u for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a Permitaioecu Ne applicant m a civil penalty of APN Number Occupancy Type
not aloe than five handled dollen($500).
❑I,As owner of the ironically,or my employee with wages list Nelr sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.]OH,Be.!.. 106 - SEWER 14 ���' eCtlODs
and Profusions Crede:The Contractor'License Law dao not apply to an owner of g
pmpeny who builds or imprl thereon,and whoddeuuch walk himselfor through his 202 - UNDERFLUOR PLUMBING
own employees,provided that such improvements Are not intended oroRered for side.If, 3101 - ROUGH PLUMBING
however,the building or improvement is sold within one year of completion,the owner-
builder will have too burden of proving that he did not hued or Improve for purpose of 507 — FINAL PLUMBING
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construe the project(see,
Busimss and Profusions Code:)The ContnnoM1 Li.
..A law sides not apply to an owner of property who Wilda or improves tkmon,and _
who contracts for such projects with a contnctor(s)licensed pursuant to the Contractor's
License Law.
late e,xj��,r��repiun der SefgJ ,B k P C for this rtason
owner Data 7,/f D
/ WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,aro of the following declarations:
I haw and will maintain a Certificate of Consent to self-insure for WoheriCompen-
tion,u provided for by Section 3700 of the labor Code,for the performance of the
work for which Nis permit is issued.
❑1 have and will maintain Workers Compensation Insurance,u palsied by Section
3]100 dr
the labor Coda,for the performance of one work for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number art:
Caren Poliay No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This secthm need not W completed If tion permit is for one hundred dollars(SIM) �
fir Icss.) '
1 ccnify that in the performance of the work for which Nis permit is issued,I shall not
rs
employ any peon in cettddddlWrry manner Q A,m become subjecua the Workers Compensation
Lewsn^CNifor sDa
Lactic 1 G /71 L
NOr I PPLICANT:It.after ma mg this Certificate of Exemption,you should
become subject Io Ne Worker's Compemation provisions of the labor Code,you most
.'O fonhwi to comply with such provisions or this permiuhall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I harchywhich thi Oil them issued( cet3W7.lending agency for performance of
Qi Lffica work for which this permit is issued(Sar.J(N],Civ.C.)
aW Q Under',Name
z 1<nder's Address
U Q I certify that 1 have read this application and sum that the above termination is
W f"' correct.I agree to comply with all city and county ordinances and sate laws relating to
0 U building construction,and hereby suthorrre eproanmiws of Nis city to enter upon the
U4 above-mentioned property for impaction purposes.
(We)agree to ave,indemnify and keep historian the City of Coconino against
rIn Nabi lines,judgments.costs and ex penia which meym any way aicmc against said City
C)7 in consequence of the granting of this permit
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REG ULAT NS.
Re-roofs
&lure of ApplicanUComnmor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant at future building otcurnal store or handle haandous material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(e)? 6� All roofs shall be inspected prior to any roofing material being installed.
El Yu
Will the applicant or future building occupant usecyuipmenl or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it harardnus air contaminants u defined by the Bay Arca Air Quality Management all new materials for inspection.
ISIrILI? ,.is
❑Yes Lyne
I have mad the hunardous materials requirements under Chapmrri.95 of the Califor.
nis Health A SNety Code,Sections 25505,25533 sad 25534.1 undersold thm ifthe building
does no Lmnendy haw mot at thit.,my respoo lily w c occupant of the
noUrt
notice anSwhichon IW dorm ssureaeracenificamof(k e. Signature of Applicant Date
unwhurircd agate am f/7 All roof coverings to be Class "B" or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent,spouse or child) will perform:
A. All the work authorized by this permit
B. _ A portion of the work
C. _ None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City Phone # State License # Type of work to
be performed
• 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
performed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder InformattiiQon (reverse side).
Property Owner's Signa e: 7�///�ll�� awe Da / -
Job Addr ss /0;77,5' S/XYZ5 9tiV DAA Permit#
Any hanges to the information provided on this form shall be submitted to the City of C pertino Build
Department.
CITY OF CUPERTINO pZ�7o Z�
REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Addres (7S
Owner's Name: r �� � P ne#• � ^�/
Contractor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info: S W�2_ S`�Ui2� &ILA-141
Bldg ❑ Elect ❑ Plum
Job Description:
Residential Commercial ❑
Cost of Project: K91L �-
Qty. if
Apf GoWe Fee ID Fee Description Fee Group
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPERMFEE Bldg. Permit Fees BUILDING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING