05100184 CITY OF CUPERTINO '^^ ' .T a "s-t/' ' � b= 11
BUILDING DIVISION PERMIT CON7TRACTOli INFO "TIU,N;$,
BUILDING ADDRESS: SASHA CUKIC PERMIT NO.05100184
r NER'S NAME: PIRMITISSUEDATE
SASHA CUKIC 02/15/2006
E: SANITARY NO, CONTROL NO.
ARCHITECrIENGINEER: - BUILDING PERMITINIM
BLDG ELECT PLUMB MECH
0 0 0 0
30o
LICENSED CONTRACTORS DECLARATION Job Description
u I hemhy afOrm Nat I am Iimnx under provisions of Chapter 9(mmmcncing
with S.clkn701111)of Divislan3.rJ Businusand Prof.W...Coda.mdmy1m.racis
infnn(OKIandeffea. ADD-FAMILY RM/RELOCATE COTTAGE/GARAGE
License Class Contractor Dae C875 ' -LIV. SP/GARAGE-4931
ARCHARCHITECT'S'S DECLARATION
I understood my plena shall he used As public mcnrm
5 u
,tt; Licensed Pnsfcssional
y3 OWNER-BUILDER DECLARATION
ZOO hereby.(Scc on 1 1. exempt from the feationCode:
C s :Any C Law for the
0o which following moon.Permit
71DI.3,BusinessandPmlcedan Co de:Any city scounty
$ which requires
a permit re Construct.tlea improve.demolish,nr a pair any swannt
_zi^v
prior=,liamscul issuance,alsothe provisions
of for wchPermit mfik a,LAw(shtemem
< (fast com incingwithSuan7000)ofDivioos3oftheft onuacrosaLImnselaw(Chaper9 Sq.Ft.Floor Area Valuation
>�O
(commencing with Section]0W)of DivisionJof NC Business and Profcasiona Codi m $215368
y $ find he Ian exempt therefrom and the basis for the alleged ecoapdon.Any violation of
Seedon 7071.5 by any applim,for a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not mon than five hundred dollars(SSW).
0 l,mo aolUepmpmy,mmycmploymwithwgesuthebmkcompeladon,
willdo the work,and the suucmn Isnot intended oronescd image(Sm.7014.Business 00
Required Inspections
sand Prafessimu Code:The icedm Oxameme.License Law rot apply m an e awn of tl p
grope ny who builds ar improves thereon.and who does such work Mmmlf or through his
own employ=,provided that such improvements Am not intended moffraed for sale If.
however,the building or improvement is sold within am yea of completion,the owner.
builder will have de burden of proving;that M did not build in improve fm purpose of
tile.).
fd 1.as owmr of the ppeny,am eaclmively contracting with licensed mnuecera
construct use pmject(Sec.7144,Business and Profossion Code:)The Conuanor's LI-
ccne Law dm not apply to an enamor of property who builds or improv thereon,And
who contracts for such pmjecb with a eomrsomr(s)licensed A...t ie the Conumn e.
Licence Law.
❑lam aemp�tt/ der Sea .B&P C for thio reason
Ckw,mr ✓rr. LA G'. K/C Dae FC3 /d—o
WORKERS COMPENSATION DECLARATION
I hereby afNtn under penalty of perjury am of the following declantiom:
❑I haw and will maintain a CcrJOpta of Consent in self-insure frr Worker's Compen.
smon,As provided for by Section 37M of the tabor Cade,for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Lannon,As required by Section
37M of Ne labor Cade,fm the performance of the work fm which this permit is inded.
My Worker's Compensation Insurance Cartier and Polity number M:
Carrico Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mils mcdm deed nothecompleted If the permit is faro=hundred dollars($1010)
or less)
I unify that in the prhmoance of the work for which this Permit is lavas,I shall not
employ any person in any mmnerw as b become subject to the Workari Commosation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making thh CcniOcae of Exemption,you should
become subject in the Worker's Compensation proviaio=of Jos Labor Co..you most
.J O faMwith comply with such provision Of this permit shall M deemed mmued.
,z.,tiCONSTRUCTION LENDING AGENCY
f^ Ihereby affirm that then I....muiction lending Agency fm Ne perfrmi of
de work for which this permit is laved(Sec.3097,Ci,C.)
W A Lender's Name
zLender's Address
U C I certify that 1 haw mad W s application and sue that the above information is
Ig, P correct.I Agrce to comply with all City and county ordinances and sou laws relating An
0 U building construction,and hereby authorize representatives of this city to enter alms the
D7 shove-memimcni property for inspection purposes.
(We)AS.e to save,indemnify and keep harmless the City of Cupertino Against
o-„y liabilities,judgments,Coss,and expenses which may in any way accrue sgain)said City
U Z incanmgm=c of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURcegg=S. �/ e � 76 IS Ub Re-roofs
Signerure of AppliosnUComramor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oe applicant or future building accupant cam or Mndk harardaw material
as defined by the Cupenino Municipal Cade.Chapter 9.12,and the Health and Safety
.Sccws 25532(4)7 All roofs shall be inspected prior to any roofing material being installed.
[3y. I1614o
Will the III or future building mcupnt vac equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaardoua air conaminanu As defined by de Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes luk
1 hove mW the huaardan materials raquiemenu under Chapter 6.95 of the Califor.
nia Health&Safety Cantle,Sections 25505,25533 and 25534.1 understand Nat if the building
dm mol c 'nil be o cream that II Is my responsibility m nodl'y IM occupant mf the
mud lnmc hlchmostbem/rFynnrta aanceofaCcnificaeOfOccupan Signature of Applicant Date
y t-f �'�fLIC /OE6 / ole.
Owner or authorized agent Data All roof coverings to be Class "B"or better G