07070111 77777777777= 7,7`7'77 777777
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
_ - PERMIT NO.
BUILDING ADDRESS:
10162 BREI AVE GREAT AVERICAN PLUMBING CO 07070111
10
PERMIT ISSUE DATE
OWNER'S NAME:
GALINA BELOGOLWSKY P 0 BOX 26942 7 7
SANITARY NO. CONTROL NO.
JE:
(408) 27 -1515
BUILDING PERMIT INFO
rARCHITECT/ENGiNEER: BLDG ELECT PLUMB MECH
pZLICENSED CONTRACTOR'S DECLARATION Job Description
UPI hereby affirm that I am licensed under provisions of Chapter 9(commencing
U Section 7000)of Division 3 of the Business and Professions Code,and my license is p I PE BUI:ST 70 FT OF 4" SEWER LINE; INSTALLING (1)
A- in full force and ff ct
LicenscClassLic.ff ONE—WAY CLEANOUT & (1) PROPERTY LINE CLEANOUT.
F p Date't-l�e-C7 1 Contractor
ARCHITECTS DECLARATION
11 e 1 understand my plans shall be used as public records
hqU
L,y Licensed Professional
ti OWNER-BUILDER DECLARATION
> I hereby affirm that 1 am exempt from the Contractors License Law for tltc
.n o following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement 1ZValuation
?< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q• 6000
1=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
`3 that he is exempt therefrom and the basis for the alleged exemption.Any violation of Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more man fire hundred dollars($500). 3751103
7 Number P Y
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7(X4,Business Required Inspections
and Professions Code:The Contractors License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for We.If.
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
LJ I have and will maintain a Certificate of Consent to self-insure for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code.for the performance of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. ha..A_P Poliry .f�11.t
Noi1 2.1..6U
CERTIFICATE OF EMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is far one hundred dollars($i00)
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
O forthwith comply with such provisions or this permit shall be deemed revoked.
Z 2 CONSTRUCTION LENDING AGENCY
ham-. I hereby affirm that there is a construction lending agency for the performance of
fYi 5 the work for which this permit is issued(Sec.3097,Civ.C.)
W A Lender's Name
Z Lenders Address
U 0 1 certify that I have read this application and state that the above information is
[t+(~ correct.I agree to comply with all city and county ordinances and state laws relating to
U building construction,and hereby authorize representatives of this city to enter upon the
W ahovc-mentioned property for inspection purposes.
CL (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hliabilities,judgments•costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Date ,t7
►y AAR
NT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
STIOt iS. Re-roofs
SfApplican Yo for
Date of F.00f
OUS MATERIALS DISCLOSURE Type
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Q(No
If a roof s installed without first obtaining an inspection,I agree to remove
Will the applicant of future building occupant use equipment or devices which all new materials for inspection.
emit hazardous air contaminants as defined by the Bay Arca Air Quality Mamagcmcnt
District?
❑Yes O No
1 have read the hazardous
in requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not cyfrently have a tenant,that it is my responsibility to notify the occupant of the
require is wh :mlfStbC�het prior issuance of a Certificate of Occupancy. Signaturc of Applicant Date
ro All roof coverings to be Class"B" or better
Owner or a rued agent Date