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07090078 CITY OF CUPERTINO BUILDING DIVISION PERMIT � fi� IRMITII�I�F PERMIT NO. BUILDING A DRESS: 1' 5 CHARSAN LN TBD — TO BE DETERMINED 070.90078 PERMIT ISSUE DATE OWNER'S NAME: DORAN DRUSINSKY 09/13/2007 SANITARY NO. CONTROL NO. NE: BUILDING PERMIT INFO ARCHITECTIENGINEER: BLDG ELECT PLUMB MECH p ZO LICENSED CONTRACTOR'S DECLARATION Job Description u I hereby affirm that I am licensed under provisions of Chapter 9(commencing ;Z with Section 70()0)of Division 3 of the Business and Professions Code,and my license is TANKL E S:i WATER HEATER ti in full force and effect. v�Z License Class LM•# t- Date Contractor ARCHITECCS DECLARATION i ode< I understand my plans shall be used as public records )a. U.�- Licensed Professional OWNER-BUILDER DECLARATION j< 1 hereby affirm that 1 am exempt from the Contractor's License Law for the -,n o following reason.(Section 70315,Business and Professions Code:Any city or county $0! which rcquires a permit to construct,alter,improve,demolish,or repair any structure prior m its issuance.also requires thea applicant for such permit to file a Signed statement Valuation r pp a g .Ft. Floor Area that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 >q $3200 t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or a 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 ofNumber Occupancy Type not more than five hundred dollars($500). 36210060 . U 0 I,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 Required Inspections and Professions Code:The Contractor's License Law does not apply to an owner of property who builds or improves thereon,and who does such work himself or duwgb 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 sok. L as owner of the property.am exclusively contracting 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 contractor(s)licensed pursuant to the Contractors License Law. 0 I am exempt under B&P C for this reason Owner Dateb WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: 0 I have and will maintain a Certificate of Consent to self-insure for WorkcesCompen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. 0 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 arc: Carrier. Policy No.: CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need riot be completed if the permit is for one hundred dollars($100) or less.) I certify that in the performance of the work for which this permit is issued,I shall am employ any person in any manner so as to become subject to the Workers'Compensation Laws of California.Date 30L 4� 9q Applicant NOTICE TO APPLICANT:If,after making this Certificak of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Z forthwith comply with such provisions or this permit shall be deemed revoked. Z OCONSTRUCTION LENDING AGENCY Er CA I hereby affirm that there is a consiroction lending agency for the performance of a> the work for which this permit is issued(Sec.3097,Civ.C.) W Q Lender's Name PZ L.cndees Address U 0 I certify that I have read this application and state that the above information is (y correct-I agree to comply with all city and county ordinances and state laws relating to 0 U building construction.and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. a (We)agree to save,indemnify and keep harmless the City of Cupertino against cA liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. Date *� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by, SOURCE REGULATIONS. Re-roofs Signature of Applican f 'Date-or T of Roof HAZARDOUS 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(x)? �� All roofs ;hall be inspected prior to any roofing material being installed. 0 Yes 9fr+o If a roof i;installed without first obtaining an inspection,.1 agree to remove Will the applicant or future building occupant use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. District? Cl Yes (�6 1 have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&SafctyCodc,Sections 25505,25533 and 25534.1 understand Waif 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 Certificate of O%__ Signature of Applicant Date All roof coverings to be Class "B"or better Owner or authorized agent CITY OF CUPERTINO 3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: patg COPY # 1 Sec: Twp: Rng: Sub: Bll--: Lot: APN . . . . . . . . . 3610060. 00 DATE ISSUED. . . . . . . : 09/ 13/2007 RECEIPT #. . . . . . . . . : BS(100002631 REFERENCE ID # . . . : 07(190078 SITE ADDRESS . . . . . : 11425 CHARSAN LN SUBDIVISION . . . . . . . CITY CUPERTINO IMPACT AREA . . . . . . . OWNER . . . . . . . . . . . . : DOT:AN DRUSINSKY ADDRESS . . . . . . . . . . : 11425 CHARSAN LN CITY/STATE/ZIP . . . : RECEIVED FROM . . . . : DOLON DRUSINSKY CONTRACTOR . . . . . . . : TBI) - TO BE DETERMINED LIC # 00096 COMPANY . . . . . . . . . . : TBI) - TO BE DETERMINED ADDRESS . . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY l,MOUNT PD-TO-DT THIS REC NEW BAL ---------- ------------- ---------- -- -------- ---------- ---------- ---------- BENERGY PERMIT FEE 1. 00 34.86 0. 00 34 .86 0. 00 BPWHEATER PER HEATER 1. 00 10.79 0. 00 10.79 0. 00 PPERMITFEE FLAT RATE 1. 00 40.79 0. 00 40.79 0. 00 TOTAL PERMIT 86 .44 0. 00 86 .44 0. 00 METHOD OF PAYMENT AMOUNT REFERENCE NUMBER ----------------- --------------- -------------------- CHECK 86 .44 #3435 --------------- TOTAL RECEIPT 86 .44 VOICE ID DESCRIPTION VOICE ID DESCRIPTION -------- ---------------------------- -------- ---------------------------- 502 FINAL PLUMBING ENERGY 506 GAS TEST 507 FINAL PLUMBING CITY OF 4--'.IUPERTINO 07 y 7 WATER. HEATER CUPEkTINO PERMIT APPLICATION FORM APN# 3 (,0 og ( C9 0 6 D , O d Date: (� 17- Building Address: I I kA2 Owner's Name: Phone#: DSS( .+ SK - Lt 'IF Contractor: �k�o��e� 2� L r..�nse#: (,�, S .�d v�vL -2 sS Contact: Phone: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect C'� Plumb C �r Mech C � Job Description: Residential Ll,,- Commercial ❑ Cost of Project: Strapped ❑ On Platform ❑ Bonded CD' New Location ❑ Replacement Qty. if Applicable Fee ID Fee Description Fee Group BPWHEATER `Dater Heater/Vent BUILDING PPERMITFEE F lumbing Permit Issuance PLUMBING BENERGY Finery BUILDING BUSLIC Business License BUILDING Community Development 10300 Torre Avenue ' Cupertino CA 95014 Telephone(408)777-3228 CITY OF Fax(408)777-3333 '-UPERTINO Building Department JOB ADDRESS: PERMIT # C) OWNER'S NAME: Qku4cd PHONE # o GENERAL CONTRACTOR: FAX # I am not using any subcontractors: Si;;nature Date Please check applicable subcontractors and co m )lete the following information: SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets &Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum/ Wood Glass/ Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting/ Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/Contractor Sign ture Date