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11090008CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10561 CULBERTSON DR CONTRACTOR: AMCHISLAVSKY MIKHAIL PERMIT NO: 11090008 OWNER'S NAME: AMCHISLAVSKY MIKHAIL 10561 CULBERTSON DR DATE ISSUED: 09/01/2011 OVNER'S PHONE: 4089217532 CUPERTINO, CA 95014 PHONE NO: Ci LICENSED CONTRACTOR'S DECLARATION F r— BUILDING PERMIT INFO: BLDG ELECT PLUMB License Class Lic.# MECH RESIDENTIAL COMMERCIAL Contractor Date I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: DEMOLITION OF ILLEGAL GARAGE CONVERSION (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: I have and will maintain a certificate of consent to self-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. Sq. Ft Floor Area: Valuation: $100 I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this APN Number: 37536019.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I 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 PERMIT EXPIRES IF WORK IS NOT STARTED to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR indemnify and keep harmless the City of Cupertino against liabilities, judgments, 180 DAYS FROM LAST CALLED INSPECTION. costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non-point source regulations the Cupertino Municipal Code, Section per Issued by-- Date: 9.18. z� Signature Date RE-ROOFS: OWNER-BUILDER DECLARATION 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 materials for I hereby affirm that I am exempt from the Contractor's License Law for one of inspection. the following two reasons: I, as owner of the property, or my employees with wages as their sole compensation, Signature of Applicant: Date: will do the work, and the structure is not intended or offered for sale (Sec.7044, Business & Professions Code) 1, as owner of the property, am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE declarations: I have read the hazardous materials requirements under Chapter 6.95 of the 1 have and will maintain a Certificate of Consent to self-insure for Worker's California Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain Compensation, as provided for by Section 3700 of the Labor Code, for the compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & performance of the work for which this permit is issued. Safety Code, Section 25532(a) should I store or handle hazardous material. I have and will maintain Worker's Compensation Insurance, as provided for by Additionally, should I use equipment or devices which emit hazardous air Section 3700 of the Labor Code, for the performance of the work for which this contamin is as deft by the Bay Area Air Quality Management District I will permit is issued. main! n c mplian .th the Cupertino Municipal Code, Chapter 9.12 and the I certify that in the performance of the work for which this permit is issued, I shall h & afety d ,Sections 25505, 25533, and 25534. not employ any person in any manner so as to become subject to the Worker's d agent:�i� C 1 F�irautho Compensation laws of California. If, after making this certificate of exemption, I Date: become subject to the Worker's Compensation provisions of the Labor Code, I mu forthwith comply with such provisions or this permit shall be deemed revoked. CON ON LENDING AGENCY I hereby affirm that there is a construction lending agency for the performance of work's APPLICANT CERTIFICATION for which this permit is issued (Sec. 3097, Civ C.) I certify that I have read this application and state that the above information is Lender's Name correct. I agree to comply with all city and county ordinances and state laws relating to building construction, and hereby authorize representatives of this city to enter Lender's Address upon the above mentioned property r inspection purposes. (We) agree to save indemnify and keep less the ity f Cupertino against liabilities, judgments, —'e, and expens which may c against said City in consequence of the ARCHITECT'S DECLARATION sng of this rmi Additio all , the applicant understands and will comply I understand my plans shall be used as public records. i all non- p int s ce regu t' s per the Cupertino Municipal Code, Section ).18. Licensed Professional Signatur. Date 'Lot, CUPERTIfNO DEMOLITION PERMIT APPLICATION COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - building(cvcuperlino.org C) U c--�� D PRnrr,.(:TAnt)kVA1; 101561 Culbertson Drv. Cupertino, CA 95014 FAVIIrf 375-36-019 ow*rn°.RNAi,tr Mikhail Amchislaysky *e'101'r 408 921 7532MArt. hallmikhall@hotmaii.com 5'121k.f ADDR15s 10561 Culbertson Drv. CITY, srA"K,11r Cupertino, CA 95014 '� CONTACT NAME Mikhail Amchislaysky PHONE- 408 921 7532 E-MAIL hailm kha l@hotma l.com STRrr,.T.�,nnurss 10561 Culbertson Drv. crrv.s�r%TF, m Cupertino, CA 95014 TAY X r)WNER ❑ o%vKFR-B17r1.DER E) 1IWNER AGENT ❑ (-.,) TP,ArT1)R ❑ ritNTRACTOR .%GENT ❑ ARCHR'EfT ❑ r,wnr,4£6R ❑ OEVELI)TER ❑ TEvAVT CONTRACTOR NAME OWNER LICENSE NUMBER LICENSETYP£ BUS. LIC,i I DNIPAN Y NAMR T-1 t.4rt- rAx STRICT ADDRESS CITY, STAT(., LH' PHONE DESCRU'TIOA Or WORK 1) remove interior walls 2) remove raised, the floor RRSIDENTIAL DWELLING t E E ()14LY F1,00RAUA UNITS iN+"t= YJrC TYIE F't' �1h11J1T1).)N '.)MMERLIAL rLOOR AREA TYpr- or (.+w "r m noN-0.9Tr)R?ftS A(,)Arn iUH Ai.'MkrR ToT.-4LVALUATTuN_ J #: -�10 V by my �ign:Iuu'c below, ] tiiiY w cath c (lowing: I ` t progeny vym or authar zed agent to act on the ptvperly owner's bchAlE 1 have "cl this application and the inforrttatitm 1 ssvide is uurect. 1 av read the I)c rip on ofWork and vcrifv itis aciuratc. i agree to comply with all applicablc local ordinances and state laws r; latnig t !lave ildin strucuon. a onze rcpt catat cs of C,upe.rtino to enter th;: above -ides) ricd property for Inspection purposes. Signature ofApplicant/Agent: Date: SUPPLEMENTAL INFORMATION REQUIRED PRIOR TO IS UANC E OF DEMOLITION PERMIT ()Fixe i ca>? oxtY Provide ,lob Number frons Flay area Air Quality Management District www.baaiamd.org fa-? 41 -749-4762. rrL it ex �'xt k Provide three copies of a site plan showing protection for any trees lU" in diameter or more at 3' above grade. _ Provide letter frons PG&E (44)X-725-3325) stating all gas and electric has been disconnected 0tyra�tn.�izn Provide a letter- of inspection, testa, and abatement of any Hazardous Materials. Letter to be initiated by person(s) 0 certified in asbestos, mercury and/or hazardous material examination. 0 _ Planning, Dept clearanve to verify building is not considered an historical landmark. Allow 10 business days. Provide letter of clearance of all vermin from a licenced poet control contractor. — Applicant shall call the Public Works Department at 408-71771-3104 and schedule a `habitable dwelling" inspection. Provide signet! Debris Bin and Recyclable Niatcriais form. Commercial Buildings Only: Provide Fine Dept clearance for lire suppression ! alarm system review. Demn,41;p 2 t11 I.d c; revived 03116111 CUPERTINO OWNER -BUILDER DISCLOSURE FORM COMMUNITY DEVELOPMENT DEPARTMENT - BUILDING DIVISION 10300 TORRE AVENUE - CUPERTINO, CA 95014-3255 (408) 777-3228 - FAX (408) 777-3333 - buiiding(d�)cupertino.org Dear Property Owner(s): An application for a building permit has been submitted in your name listing yourself as the builder of the property improvements specified at: SITE ADDRESS CbOC �� t�Gtii APN BP# /U ( j�(/ OWNER NAME t A ` J I OWNER ADDRESS , DESCRIPTION OF WORK: We are providing you with an Owner -Builder Acknowledgment and Information Verification Form to make you aware of your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner -Builder. We will not issue a building permit until you have read, initialed your understanding of each provision, signed, and returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless you, the property owner, obtain the prior approval of the permitting authority. Fm OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION (DIRECTIONS: Please read and initial each statement below to signify you understand or verify this information.) �W_1. I understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner - Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material personally. I, as an Owner -Builder, may be held liable and subject to serious financial risk for any injuries sustained by an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not provide coverage for those injuries. I am willfully acting as an Owner -Builder and am aware of the limits of my � � /f/�innssurance coverage for injuries to workers on my property. � "ter v 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for /� ,1 the construction and are not hiring a licensed Contractor to assume this responsibility. f "V' , 3. 1 understand as an "Owner -Builder" I am the responsible party of record on the permit. I understand that I may protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her name instead of my own. (�, 4.1 understand Contractors are required by law to be licensed and bonded in California and to list their license numbers on permits and contracts. 15. I understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the 4total value of my construction is at least five hundred dollars ($500), including labor and materials, I may be considered an "employer' under state and federal law. Ulk 6. I understand if I am considered an "employer" under state and federal law, I must register with the state and federal government, withhold payroll taxes, provide workers' compensation disability insurance, and contribute to unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject me to serious financial risk. tA4AA7. I understand under California Contractors' State License Law, an Owner -Builder who builds single-family residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work is performed under contract with a licensed general building Contractor. 8. I understand as an Owner -Builder if I sell the property for which this permit is issued, I may be held liable for ancial or personal injuries sustained by any subsequent owner(s) that result from any latent construction defects in the workmanship or materials. OwneYBuilderForm 2010.doc revised 04/14110