02070116 (2) CITY OF CUPERTINO -- '
BUILDING DIVISION PERMITCONTRACTOR-INFORMATION: '
BUILDING ADDRESS: PERMIT N
10781 GASCOIGNE KNOLL SYSTEM CORP `02070116
Owg� I NAKHIMOUSKY 5375 CLAYTON RD APPLICATIGNgItf§Y2OO2
NONE:
(925) 787-5626 SANITARY NO, CONTROL NO.
E o ZO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
6.2 2 LICENSED CONTRACTOR'S DECLARATION Job Description
z:qqq 1 hereby.M m that 1 am licensed under provisions of Chapter 9(commencing ADD A/C (3 TON)
w 1_ixis in Section 0000)of Divisive J o(Ihe Business and Pmfessi ns Code.end my liccnu 4 is in tali forces eRe 1.
ec x< Linnu Cl s Lic.trContr_ O Y I
u. Oam �� SDEC ti - ARCHITECT'S DECLARATION
0
g I undemmnd my plans shall be used¢s puhlie«cords
001 Licensed Professional
6OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License law for the $2000
C?< following reason.(Section 70313.Business aid Profession Code:Any cityar county
E F G which requires a permit to construct alter,improve,demolish.or repair any structure
3� _pnwl
as issuance,elso«q the ar,plicam forsuch pennnmfilea signed statement-
thai n'.sIcimcd pdisuen,Idiot,po l ios of Ne Contractors License Law chapter!) 3 B'(],BIB&AYOI
(commencing with Secain'1000)ofD ion 3 arm Business and Professions Code) �'',plv^s I' t,: S. �_ . .Y..a i'.+P {.I, Valuation
or mal he is exemptthertfmm and the basis for the tiNt rd exemption,Any violation ' '
-of Section'9031'S by any applicant for o permit subjects the applicant to^civil Penalty OCCllpancy I�rpC
rot not more m.n Bat Hera«d amlars(gsoot 3 0 CPN ; r;�,l;' est
C1 I.as owner of the limitary.-1 my employees with wages as their sole mmpensation, 303 - ROUGH MECHANICAL
will di'woik:lad the a,met.R-is-not imcided'or"offered-for sole'(Sec:0044, _ , f°
ow .r,.-
Business and Pro(esxions Cedc:The Contractor's License Lew does not apply to an 5 01 - F I NAL I�ISERGY
ncro(propery,Who builds or improves thereon,and who does such work himself
al Ihrou n his own employees.provided that such improvements are not intended or
-ofereC __.__. .--- ....
;, o7ule:IL�owever.lnenuildingorin;pmvememia+mtlwdnmaneyearar __. .. 502_-_- FINA.L...PLUMBING-'"ENERGY'--- --- ---
completion,the ownenbuilder will have the burden of proving that he did not build or
t� rq•.',"401.�u
improve ter pnryote af+ate.). 503 - FINAL MECHANICAL ENERGY .
------505 ------F-INAL-
_ c ❑Laawnerofthe Property,am Business
ad Prof..gwimlie)no art....o -- -,t--�_,.,li,-.1-i------_._.__
mnawntheaw project(Sec.T044.Business and Professions Code)no Comhereon 507 - FINAL PLUMBING
z
License lawdosenot foapply I^ouowner thprogenywho buildsor simprovesthereon, i
5.
-and who.commcts fw.such.projec¢.with.a.mntraclor(s)IicensW.punuant.Io she _._.,___..._S.O B...,...FINAL_.MECIiANI L
a CAL_._.__-....:._..__...5e'e.
Commctor sLicensela
❑tem exempla c � �;8&PCfonhts mason �,('ti (,k:',•,Nrl,- t
Ovine Ci R Die .A FINALeo 'll
WORKER S COMPENSATION DECLARATION
'1 hereby effinn underpenalty of perjury one of the Following declinations;-'
d ❑ 1 heve'tInd'will meinuin e'6ABbaie of Consent to uIfinsure far Worker's AUG 0 7 2002
Comparmumi:u;Provided (arby Section 3700 of thc-labor Code. for the
pe (his permit is issued.
rfo n f Ne work f h h
h end will tndlma Workers Co(nNotatio 1 sumnce as egoired by section
BUILDING
,mer y FICA- OF EXEMPTION FROM work hi h this permLL is
Policyom berare
s00 of the Labor Code f r the performance of ha' o
ed M Workers Codpens ion l sure ce carter and'
u
(� G E Aran N �a933
v'�I t CERT( cY WORKERS 1 ( s l ~t �ll; t l't
. -ss COMPENSATION,
INSURANCE-
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'rt�I s (TTu se;Ion need not h tom IeieA if the -, _-' -_..
p permit is for ane hundred dollars f, i\:. L.':.1 I:": `•• (. •.I L, ;tiil'! rc1C
(SI00)mhon.).1
.i ..._.... ...i:_n - i .,..�.,--:.. .,'•o.. c .
work W:..oir
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certify(not in thephamcebf me o k(r which th s permit ii named.I
;lm l sem to en, crIbame s bJeo
Com nmu , Cedomia.Dain
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-
ppinant'
'NOTICE TOANT If. this Cast ion,you
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emin
z bcoothe WorkepCompensation Per monst.f you
Forthwith comply un s eh provisions or this Permit shell he deemed ranked.
'I CONSTRUCDONLENDING AGENCY " "' a 1
F f 4 hertb which this the l e c n t n o Ind' enc for the a formance` ,^
a '' Y . . g 6 Y P tl" t"f
A r fate woione"r'which this Permit issued C.
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Addtt
Z Lcnd r it. -'. , . . ... sti 1::xr';"11' 1.
V15 c I emfy mat I he a reed this appliceoon andu+m Nat the about mformm an n '
9w.. iormna,egme Io comply with ellmy and county ordinances and stem I..relating
Oc�7 to building constrdetian,and herebynuthodze rcpmient+0ves of this city to enter upon
r W the eb mentioned,property for inspection purpose
y,-lyt mdemmpesesk which
tanywa ofc al ie"stsaid
LU Fq
liabilities,judgments,seq costs and expenses wh ch may m anyway w y cane age nst said
U
Cryy n co sequence or the grenudg of this pe a H;
AppL7CANT UNDERSTRND -LL COMP KITH ALLN POs`JT
souacE REGuunGNs 7 Issued by: Date
t SignemR of ApplicoptrContn tort ' > Dae Re-roofs
t e�H oaY3sy {�I«�N^ attupm�S913anddihe�'alth°:�a same Y ''�TYPe of Roof'.;,: .k-!
_ ... All.roofs.shall.be inspected.prior_to.any,roofing material being.installed........ ....._._
ry 1;n WII the applicnm o tutu a budding gi'cupant use equip t ,geneg1 wgWb If a roof is installedg P without first obtaining an'ins ection's'I'ag i'ee'to'iemove
ri
all new mate
emit haiutlws ser contammenti ss defined by the Hay Area Air Qaaluy MelieQemenl - '
Dteldat+ , als for ins ection. Applicant understands and will comply with
�Ycs P
�" , ,all non-point souice iegulado`ns.,,, .r•r.' :t ,r"rlf'
1 h mreeA'Ihe hazNdous materials rcqu rcmmts.urAer Chapier h 93'of the
C+lifomu Halm'&Beteg Code.Sections 3]305,33533 end 3SSJa Punden.ad that
f the bulltl ng does ria rte dy h ve i-ilenl theist i my .p nstb lay ton u(y the - " . - - .. ..I "' --
oepup m of th rcqu icm Hist h ch m r m i p or to I seance of a critic to of
/ Occup oy sus' t_ )
7�9�•L Signature of Applicant Date
o ne Mr-, e,sent "Oln - aD Ie All roof coverings to be Class "B 'or better ' -
--OFFICE-'-_.
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