07070183CITY OF CUPERTINO
BUILDING DIVISION PERMIT
11ILDJl16 AARf'bRET AVE
OWNER'S NAME:
ii
GALINA BELOGOLWSKY
NE:
ARCHITECT/ENGINEER:
p Zo LICENSED CONTRACTOR'S DECLARATION
ul 1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
Z UW with Section 7000) of Division 3 of the Business and Professions Code, and my license is
= a. in full force and a #!L -2&
�� 3
t v� z Lice isc Class Lic. #
p Datc Contractor
F u ARCHITECTS DECLARATION
i aa
< 1 understand my plans shall he used as public records
�yU
U, H Licensed Professional
o a OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
3�-
jp O following reason. (Section 7031.5, Business and Professions Calc: Any city or county
e m 9 which requires a permit to construct, alter, improve, demolish, or repair any structure
" y prior to its issuance, also requires the applicant for such permit to file a signed statement
? a that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
o-=- (commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars ($500).
❑ 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. 7044, Business
and Professions Code: The Contractor's 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 sale. 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.).
❑ I, as owner of the property. am exclusively conuacting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a comractor(s) licensed pursuant to the Contractor's
License Law. B & P C for this reason
❑ I am exempt under Sec.
Owner Date
WORKER'S COMPENSATION DECLARATION
CHAMPIOIS PLUMBING
PERMIT NO.
07070183
PERMIT ISSUE DATE
2059 CAMDEN AVE 07/23/2007
SANITARY NO. CONTROL NO.
(408)43-1507
BUILDING PERMIT INFO
BLDG ELECT PLUMB
(�
Job Description
REMOVE b: REPLACE SEWER LINE.
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Workers Compen-
ation, as provided for by Section 3700 of the Labor Code, for the performance of the
✓ork for which this permit is issued.
-1 1 have and will maintain Worker's Compensation Insurance, as required by Section
700 of the Labor Code, for the performance of the work for which this permit is issued.
dy Worker's
CCompe*aLl Ipsurance carrier and Policy number arc:
:airier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WO ERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars (3100)
Ir less.)
I certify that in the performance of the work for which this permit is issued. I shall not
omploy 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 Certiftcatc of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that 1 have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorise representatives of this city to enter upon the
abuve-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOU CATIONS. F;
/Date
L,q. Ft. Floor Area
3 7 5110 3 , 7 ?Y61 Number
U HAZARDOUS MATERIALS DISCLOSUKh-
Will the applicant or future building occupant store or handle hayardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Hcallh and Safety
Code, Section 25532(a)?
❑ Yes ❑ No
Will the applicant or future building occupant use equipment or devices which
knit hazardous air contaminants as defined by the Bay Arca Air Quality Management
District?
❑ Yes ❑ No
I have read the hasardous materials requirements under Chapter 6.95 of Utc Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 understand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a C5,yr1catc of Occupancy.
.. i_ — J
Owner
C), A //,� S/d �-
Issued by
Re -roofs
Type of Roof
Valuation
$4500
Occupancy
Required Inspections
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new r.Iaterials for inspection.
Signature: of Applicant
All roof coverings to be Class "B" or better
Date