06030099 (2) CITY-OF CUPERTINO ? tr+'+ ' � "" ' ` +^k
BUILDING DIVISION PERMITCTTRACT.OR INF®RMAT�ION.�
BUILDING ADDRESS: PERMIT N0.
10280 CALVERT DR
WNER'S NAME: PERIAn ISUEDATE
LEON PYATIGORSKI 1000 N RAND Pt?, #112 ' 03/20/2006
NE: SANITARY NO. CONTROL NO.
(866) 293-3031
/ ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO ELECTPLUMB MECH
LICENSED CONTRACTORS DECLARATION C L n
1 hereby affirm(hat I am licensed under provisions of Chapter 9(commencing
with Section 7.x0 of Division 3 of Me Business and Profculnna C end mylkerueB
'Ln
fullfamcand ° REPLACE HOT WATER ALL 6 YR
Lken Clus _ Lk.t �
Da¢ Conosem
RCHRECTSDECLAr RAn. MAY 2006
1 understand my plans shall be u used public records
J U
It Licensed LicenuI erobyaional BUILDING
f I ince IN
'gN OWNER-BUILDER DECLARATION U LV'
i 0 S I heMhy.(Gere Net 1 1. exempt from J r Cssion o License Law for the
p O following moon armit t WA1.5, t.alas and Improve,
dcoo.Code:Any city or county �`CJ O 0
$to which its issuance.
•permit re co.lroet,alar,n from,h remit
t or repair any uumum
—i y prior m i6 caned purse reqnt he MS(hevisio or forMe sucCon permr Livenso life a Law xtsumca
that he islicensedWitpursuantion 7 the pmvislo.nfth Me Contractors Prollaw(Chepur9 Sq.Ft. Floor Area Valuation
thammcnc xempthherefrom 00)and
bassfon rn(NCByed exemption.
An virs olde)ation
or
of
Net be u exempt therefrom sod Ute buts for Ne alleged eumptim.Any violedon of
Section 7031.5 by any applicant for a permit subjects the eppllnnt to a civil penally of jkpiq NuFn&i Occupancy Type
no(mace Nan five hundred dollars(5500).
❑1,as owner of the property,or my cmployan with mVA as their auto mmpenadon.
will do the work.and On sudc(ue is net rounded or offered for salc(Sea 76th.Businw Required Inspections
and Prefixal..Code:The Comnrs tNLiam Low door nut apply m a e ns owner of q p
pr.p t-ty who build,orimprows thereon and whodoess.h work himselfor through his
awn employees,provided that such imprommenus are not amended a offered for sale.if.
however.the building or ImpwwmenI is an]If within one year of completion,Ne ow.m
builder will hew the Baden of proving that he did not build or improve for purpose of
sale.). -
❑I,a owner of the property.am re.lamniy...cousin,with licensed roaumrs(o
construct the project(Sec.7044,Business and Pro(esuio.Code:)The Contractors Li-
came taw don not apply to an owns of property who builds or improves Neuron.and ,
who enormous for such projects with a contrutar(s)licensed pursues(to the Commuters
License Law.
❑i ore esemp(under See. .B R P C for this mann
nor Daus
WORKER'S COMPENSATION DECLARATION
I hereby affirm under forestry of perjury me of the following declarations:
❑1 ham and will maintain a CeNOesm ofConwnuo self-i.uze for Workees Compere
union,as provided for by Section 3700 of de labs Code.for de Performance of Ne
work for which this permit is Woad.
ve anda
will maintain Workers Compe.alion Insurance.u required by Section
00of NC tCnde,forNeperformance of Neworkforwhichthis Pemritis Issued.
My Worker's Com�pan�ssedan Insurance carrier and Policy number am:
Carrier:�'rm ITC Policy No.:L'y,ON'MlLiA tal
CERTIFICATE OF FXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Missal..ednotbecampleed if(ha Permit us faro.hmn cddollan(5100)
or Ina)
1 certify that in Ne performance of the work for which this permit 1,Wood,1 shall not
employ any Pelson In any mararm as to bemme subject to the Worlmot Comp ommon
U.of California.Dae
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Eamption,you should
Income subject in the workers Compensation previsions of Ne labor Code,you mum
,JO forthwith comply with such provisions or this permit shall M m
deeed wanted.
z55 CONSTRUCTION LENDING AGENCY
(-.� I hereby affirm Nat there is a construction lending agency for the performance of
{Y, the work for which Nis permit u iaaoed(Sar.3097,Ci,C.)
OWi Q Unae.Name ,
ZD Z Lenders Addma
U C I cemfy that 1 haw read this application and sue that the show Information Is
1y correct.I agree to comply with all city rend county ordinance,and some laws relating to
CV building consw6m,and hereby authorize rmMaentatins of this city to enter upon the
{2.1 shove-mentioned pmperry for inspection purposes.
gy, (We)agree to saw.indemnify and keep harmless the City of Cupertino again,
h Imbilides,judgmenu,costs and expenses which may in ayvay amuse against said City
V 7 In canaquena of Ne grating of this permit,
a APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SQU.Rq REGULAl70N5. -6�^
�Ley `! Re-roofs
SigSignatureSignuof AppliwDO DaDa
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Nen Cupentafutureipal ng.aupaptsaeorhandle Halt
altanmateriel
u de.Sed o Ne Cupertino Municipal Code.Chapter 9.@,and Ne HcuiN and Safety
Cork, 0 es 23532(e)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes �jNu
Wi11 the epplicat or future building c supam use equipment or Jcvica which If a roof is installed without first obtaining an inspection,l agree to remove
emit haardna air cenmmi.nts as JeO.d by the Bay Area Air Quality Management all new materials for inspection.
Dimia7
❑Yes A9 No
I haw real to harden materials requiromcnts under Chapur 6.95 of the Califor.
nice Hat"SafctyCodc,Saoans 25515,35533 and 25534.1 undcrstsnd Naif Nc building
does not currently ban a mars,Nn It is my responsibility In nod l'y Me,aceupa(of the,
r Irements which mumbemmpd.la iscremcofa Cenifi"w.f Occupancy. Signature of Applicant Date
rA''fi'e Qy -%o All roof coverings to be Class "B"or better
Owner or authonad agent Dau
CITY OF CUPERTINO
3 of 5 PERMIT RECEIPT OPERATOR: suem
COPY # 3
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 37518018.00
DATE ISSUED. . . . . . . : 03/20/2006
RECEIPT #. . . . . . . . . : 33636
REFERENCE ID # . . . : 06030099 '
SITE ADDRESS . . . . . : 10280 CALVERT DR
SUBDIVISION . . . . . . :
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : LEON PYATIGORSKI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : METRO MECHANICAL
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : METRO MECHANICAL INC
ADDRESS . . . . . . . . . . : 1000 N RAND RD, 4112
CITY/STATE/ZIP . . . : WAUCONDA, IL 60084
TELEPHONE . . . . . . . . : (866) 293-3031
•
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
__________ _____________ __________ __________ __________ __________ __________
BENERGY PERMIT FEE 1.00 34 .86 0.00 34 .86 0.00
BPWHEATER PER HEATER 1.00 10.79 0.00 10.79 0.00
PPERMITFEE FLAT RATE 1.00 38.37 0.00 38.37 0.00
__________ __________ ---_------ ----------
TOTAL PERMIT 84 .02 0.00 84.02 ' 0.00
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
•
Community Development
0 Torre Avenue
CupeOrtino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
"SCUPEkTINO
Building Department
JOBADDR10 2 O ES�e V�� PERMIT # /; 603
O3eV
OWNER'S NAME: Le p� Q �- ; o,t-g(�; PHONE # 08 q�rls 0-1"
GENERAL CONTRACTOR: 1 n FAX # 8 t-(t Lf 4f
I am not using any subcontractors: `'t � �A Q- CLQ-4 3'2 O-04
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
• Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing 12 eJ-KQLl, 21
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
WATER HEATER pi�6360y�
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
Building Address:
O ' Name: Phone#:
TLNn A- 00y
nt actor: E D0
n and ca, b" i n - ,m� License
Q,a #:
Contact: �1 I Cupertino Business License #:
G`7
Building Permit Info: 1
Bldg ❑ 1 Elect t /Plumb U Mech LY
Job Descripti
11 CkCQ 1( "tQ� -l��C �t
Resid1entia Commercial ❑
Cost of Project: �, O� Zk)
Strapped U On Platform ❑ Bonded
New Location ❑ Replacement ❑
Qty. if
Applicable Fee ID Fee Description Fee Group
BPWHEATER Water Heater/ Vent BUILDING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BEN ERGY Energy BUILDING
BUSLIC Business License BUILDING
•