05120069 (2)CI TY OF CUPERTINO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
YURIY PRAGIN
PERMIT NO.O5120O69
1164 ELMSFORD DR
OWNER'S NAME:
PERMIT ISSUE DATE
YURIY PRAGIN
12/13/2005
E:
SANITARY NO. CONTROL NO.
ARCHI7ECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONfRACIOR'S DECLARATION
'
Job Description
1 hereby afllrm that 1 Am licensed under provisions of Chapter 9 (commencing
with Section 701)(3) of Division lar du Bus. and Protossionx Code, andmy license is
in full mice and effect.
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REPLACE WINDOWS W/STACCOPLACEMENT
License Clan Lk. M
qv— v"
Dam Contractor
' ARCHITECTS DECLARATION
I understand my pons shall M used an public mcnrN
�db}y
Licensed Profession,)
OWNER-BUILDER DECLARATION
6b '
1 hereby Affirm that 1 em exempt from the Curvatures License Lew for the
following moon. (Section 7031.5. Business and Professions Code: Any city m county
Ax$6000
which acquires a permit to car erm re uct, Blur, improve, demolish, repair any structu
'0
pilar to IIS issuance. also requires the applicant rarmth pommll to III. a signed eummmll
that be, is licensed pursuant Wsite provision, ofthe contractors ucerse Law (Chapter 9
Sq. Ft. Floor Area N V*f'Valuation
(commencing with Scotian 7000) of Division 3 of the Bushmen end Profusion, Code) or
that he is eumpt therefrom and the bub for the alleged exemption. Any violman of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
r Occupancy Type
rot mart than five hundred dollars ($500).
❑ 1, as owner of the pmpeny, m my employees with mges u their sob eampenudon.
Required Ins echo+
will do the work. and thesuucurm Is not intended moffmad forwe(Sec. 7ON. Bualneu
and Professions Code: The Commences Limme, Law dw not apply 10e an owner of
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property who builds Or improves thereon. and whodoessuch wank himselforthmugh his
'
own employers, provided that such improvements are not intended oroRered (mole. If,
hmevm. ebuilding or improvementlaanld withironeyeanormmpleeon,lheowwu,
bullde B law the burden O(proving then he did not build a improve fm puryese of
u
1, u moor of the property, am exclusively contracting with licensed conummas to
m
construct dm project (Sec. 7044. Business and P aO:ulon, Code) The Common'! U.
ccnse law alma Out apply to An owner of propeny who builds or Improves daemon, and.
wMmnmacto ra hpmjem with •comactor(O licensed pursuant to time Comanctors
Lken,e Lew.
❑tem exemp n1u5 BdvPCf Nis
Owner Z
.
,
Can
W RKER' COM ION DECLARATION
I he by Ise soil of per)ury mu of the fallowing deowtions:
IhareLl-m will msinuin•CeNfiesteaf ConsemurwlGin,vac for Workeea Compen
neon, u provided (m by Section 3700 of du Labor Code, for the performance of the
walk for which this permit ie issued.
❑ 1 haw old will maintain Workers Compensation In,uranw, u requited by Section
3700 of The Labor Code, for The performance of the wait for which this Forest, Is Issue t
My Workers Compensation Insurer= carrier and Policy number ice:
Cartier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thbautlon wood rot be cmnplemd ff the ported la(ormlc hundred dollars ($1010
or less.)
I molly Not in the performance of N workfryn which this permit is Issued, l shall nm
employanypcnonlnmyman r t b Ib'ecHotMel cos Compen,Nan
/q
Lamof Califomla Dam l
Apph t -A- Tei
„
NOTICE TO APPLICANT: IL elle, talking this CeNOcam of Exemption. you should
became subject to the Workers Compensation provisions of the Labor Code, you most
faMwith comply with such provisions or Nie permit shall M decmod rooked.
CONSTRUCTION LENDING AGENCY
I hemhy Affirm Net dart B a construction lending agency for the perfmerance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
lender's Name
'
Lender's Address;
I cerdfy that I hew nod this application and sum that the &how Information u
coned. I agree to comply with all city and county ordinances ad tum laws rela0ng he
building construction. and hereby authadm representatives of this city To enmr upon the
Abow.amadamed pmpeflY for InspeCTiOn ParPOSCL
(We) agree In saw, indemnify and keep harmless, the City of Cupenlno against
ihbili es.jtr emu, tom andexpenms which may In any weyeccfue agaln,tssid City
AP eof thc UNDERSfANOS Aof s permit.
COMPLY WITN LL NONPOINf
Issued by: Date Z^ /�^fins
SOUR REGULA
Re-roofs
Type of Roof
_
nuum o H AR IN US MATERIALS DISCLOSU E Dam
1 aPpliesnt uncac Wild'ngoccupmluorcorhaM chnaAovsmatenel
Asdefined y Ne Cupenina MunId Code. Chapter 9.11, and the Health and Safety
ede, Sccean gss31(a)? -
All roofs shall be inspected to any roofing material being installed.
❑Yu No
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or futons Wilding occupant I@ equipment or devices which
it hsmrdnu air contemian s u thud by the Bay Asea Air QualilY Management
all new materials for inspection.
intact?
❑Yea No
Ih the haumeusmmHabmquiremenuundcrCMpw6.95ofNc Califim.
an Health etyCodc, Scedms 25505.25533 and25534. l understand matfthe building
does not c rely haw a t, m
to notify use aapant of the
armiaeum sante esmofoca r•
require tch
ignature of Applicant Date
list
A f '�0
All roof coverings to be Class "B" or better
weer or anlb ager Da