06050094 CITY OF CUPERTINO7,�
BUILDING DIVISION PERMIT cc�v, Ra�G�riR�oMAT ^°
BUILDING ADDRESS: PERMIT NO.0 6 0 5 0 0 94
21796 STEVENS CREEK BLVD
OWNER'S NAME: PERMIT L95UH DATE
SASHA CUKIC 006
NE: SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCH
0 I�
18 LICENSED CONTRACTOR'S DECLARATION lob Description
CC i Mreby affirm that I am licensed under prevision of Chapter 9(commencing
? U with Section 7000)of Division 3 of de Business and Professions Code.AM my licenseis
+ iofullforecandeRed. INSTALLING ICBO SKYLIGHT
)M 4 Licuen class Lie.«
Dade Contractor
f r7yARCHITECTS DECLARATION
< 1 undersa
nd
my Plans shall he used as public records
U
a Licensed Professional
5
OWNER-BUILDER mDECLARATION
aI Mara aRinn then 1 1. uempt from the fessionsC l Licence Law far the
p o following reason. ertian 703 I.S.Business and ve dcaum Coir::Any city m county 110 0
39�+ which requires a permit re uirawc4 pMe improv,deermitt ore a sig ed swmum
pnortoiussued pursdmquithe lM epions of for mchpctor's ccuseiaw(Chatem
€< IhalhcislicemcdpunuanrwlhcpmvisiomoflheConuecmr'sLiccualaw(Chaptc9 Sq.Ft. FloerArea Valuation
A p (commencing with Section 7000)of Division 3 of No Business and Profrssions Code)or
i $ that M is exempt therefrom And the basis fm the alleged eAempOan.Any violation of
Section 7031.5 by any applicant fur,A Permit mbiccu the APPlicmr to a civil penalty of r Occupancy Type
Mt more Nan five hutMred callus(15M.
1,uo ofthe property,or my employers with"tea As Chehmle=Penadon.
will do thework.and thesuumure Is netimended or offered mrsale(Sec.704,4,Budrcss Required Inspections
4,M Professions Code:The Conuacmrs License Law does tot apply to an ownor of q P
property wine builds or improwa assume,and who doessuch wart himself or through his
Over employers•provided thatsuch Improvemanu am Cur intonded mallered(areas.if.
however.the building or Improvement is mid within One year afcompledem,the ewrcr-
Wilder will have the burden of proving that M did not b hl or improv for purpose of
sale.).
(n 1,As avner of the property,am exclusively canuuting with Bmnsed cenaacmrs he
construct the project(See.7014.Basins and Pmfesmou Cade:)The Conumturs LI-
Oman Law does not apply to an ownar of property,who builds or improves thereon.And,
who convects for such projects with a contramor0)licensed purwm te theComraduh
Lice.Law.
❑lamexemptundesSam /` .BAPCfa
orthismon
Owner ..S�s t� L4 e C Dau _
Ailk WORKERS COMPENSATION DECLARATION
1 thereby affirm under penity of perjury oro of Che fallowing demuutotm
1 ham and wRl maintain ACa ufiaw ofCommum to self-insure for WobNsCompen-
sation.u provided for by Section 3700 of the labor Code,fm the perfomtadtoe of the
wart for which Nis pewit is issued.
❑1 haw and will macWe Workers Compensation Inadaance,As required by Senian
3700 of the labor Code,for de performance of the wort for which mu permit 4 issued
My Workers Compensation hummoce artier And Policy number ase:
Carver: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE r
Inds section reed notbecompleted If lbs permitisforenehundrtddolWs(SIM)
or leu)
I cmtiry mm in the performance of the weh fm which ibis permit is issued.I Ihall nm
employ any person in any manrcrmumb ambmth.409m 'Compenetion
Laws off Cati(omja. a &F
Applicant S
NOTICE TO AP s the woe:B,commaking ms CWOM Of of ExAW Cod yes should
bueanesubject y Ute Wohmro Cmnpeuatiinermit"or the LAW Code.you muss
0 O forthwith comply with such provisions or this pewit shall he duemed revoked.
Z y CONSTRUCTION LENDING AGENCY
t�4 IMmby sRirm«tad mem is a commucdnn leading agency far teperfmmuec of
CL> the want for which this Perch Is mutual(Sec.3097,Civ.C) .
W Landers Name
:)2 lander:Addmes
U0 I Certify that I have read this application AM sum Chad the above Weumadan s
U.f"' corm 1 agree to comply with all city and county aNlvnaes and sum laws misting to
O(, building connection and hereby autborire reprtaentnives Of this city m Cron uPnn me
l21 above-mcutiuncd propeny for impaction purposes
(We)agree to save.indemnify and keep humlrss the City of Cupertino all
i�y IiabiliOes.JWgmenu,came and espeueswhich may inmyway==against said City
L)Z in couequmtCe of the grantins of this Pmmil.
.. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 62� Date
SOURCEREO T�IOyS. //—
SC C �'�C — "6 Re-roofs
sigwue orAppBanUCamemor DataOf Roof
HAZARDOUS MATERIALS DISCLOSURE Typo
Will the applus nr or future Wilding occup nauum or handle hazardous maerfal
as defined by she Cupertino Municipal Code,Chapter 9.12.and de Health And Safety
cede,Seetian 25532()7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes 13Nc
Will the applicant or future building occupant use equipment a devices which If a roof is installed without first obtaining an inspection,l agree to remove
mit hemIan air meumtesne as defined by the Bay Area Air Quality Management all new materials for inspection.
Dish."
❑Yrs tR T.
I Mac mad the huamws mamrias mquuenern under Chapur 6.95 of site Califor-
nia Health&Safely
alifor-
nsHealthASafery Cade.Secdare25305.25533 rea 25534.1 muckneased matifde Wilding
does tet cmrendy Mw•tenant.mat It s my mspom bility 0 Mary she oaupenl Or the
negmrentenah or rnrcar. o(Occopancy, Signature of Applicant Date
, All roof coverings to be Class"B"or better
Ownm or mthorircd.genr Data