09110053 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 11607 CEDAR SPRING CT CONTRACTOR:THE HOME PERMIT NO:09110053
IMPROVEMENT SOURCE INC
r""*IER'S NAME: ALEX LYZSHEVSKY 1655 WHIPPLE RD STE 22 DATE ISSUED: 11/09/2009
(i..iVER'S PHONE: 4088651594 HAYWARD,CA 94544 PHONE NO:(510)675-0009
❑ LICENSED CONTRACTOR'S DECLARATION gUILDING PERMIT INFO: BLDG r 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:REMOVE SHAKE ROOF,INSTALL 30LB FELT,
(commencing with Section 7000)of Division 3 of the Business&Professions GRAND CANYON
Code and that my license is in full force and effect. ASPHALT COMP SHINGLES 24SQ
1 hereby affirm under penalty of perjury one of the following two declarations:
t have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as pmvided 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 Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area:0 Valuation:$9000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:36654067.00 Occupancy Type:
APPLICANT CERTIFICATION
1 ceRify 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
to building construction,and hereby authorize representatives of this city to enter pERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accnie against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant undetstands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
e�-•���e Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a mof is
1 hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the stcucture is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
const�uct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
1 have and will maintain a CeRificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with 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 Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION [hereby affinn that there is a constnxction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
�he above mentioned property for inspection purposes.(We)agree to save Lender's Address
,. mify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accnie against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date