05010117 CITY OF CUPERTINO :�- �*� �s»sy
BUILDING DIVISION PERMIT ;;CONtuA ,TUR IN UT.LMA
BUILDING ADDRESS: MARINKO BALDE Pmmrr N0h50101 J.7
ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY OC. NTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGO ELECTO PLUM
O MO
u0c LICENSED CONTRACIOR'S DECLARATION Job Descri tion
1 hm h
mby affirm I am licensed under provunstoof Chapter 9(mmmencint P
with Smile.7000)of Division 3af do Businasaed Professions Code,and my became is
^pp
to fail finea
LicenseimmucClw Lk.NandcSFDWL-3 STORY (2400 ' -LIVING)
p la Z
mor
�1. eons TSDECLARATION
ARCHITECTS DECGARAGE-625 SQ FT/BACK LOT
I unMntanm my plena'hall W wed as public mcneds
U
3 G Ser LkenmJ Professional
3 OWNER-BUILDER DECLARATION
i I hereby.(fins that 11. exempt Imre th Csskmis o :A nme Law for IW
O O .1fich re reams.(Section l(131.6,Bwircm and Pm.de oli Cade:Any city or county
3 Pi which mquima•issuance.Permit is carouser.applicant tar W pmve,demolish.or repair any unxture
_Zy priarmiucensdpummmindosth iosof for swhpernkmfieaeLa (Chaps enl
< (that he comencinns it pSemant mtW provisions of the Conummrsoul ftl Law(CWpter9 Sq.Ft. Floor Area Valuation
$
(commencing Section7000)nd of basis for
of he alegaima,udon.Any
Cod)W
Net he a tempt d"•�(mm and dte buts Tor Ne alleged assumption.Aar Notsdon of
Section 7031.5 by any applicator foe a permit subjects the applicant m•null penalty of APN Number Occupancy Type
7not arc Nan five hundred dollen(6500).
1.u owner of the property.or my employees with wages as their mle compensation,
will do line work end tedatmclum i,not ln¢ndedm Offered for sale(Sec.7044,Businhas • OO Required Inspections
and Pmfnte
esalau Code:The Coacmr's Liame eta Law mnot apply m an owner or
9 ns P
property who Wilds orimpreves themon,and whodoes suchworkmmsel(orthrough his
Own employees.provided thatsuch improvements art not InmMed eaoffered(orale.IL
however,the building or improvement Ismid within am year ofcompletion.Na owner.
builder will have the burden of pmviag del he did nm Wild or improve fee purpose of
sans.).
3.as awes(of Use property,am exclusively contracting with licensed cenuactura in
censuwt On pm)ms(Sec.70/x,Business and Probations Code:)The Contractors B-
ows Law does not apply m an ower of property who Wilds mbnpmw thermn,and,
who convects rat such projects with a conuwitoo )Ilansed forwent m LOU Contractor's
License Law.
❑I am seerrept under St B k PP C fear thinprtmon
r /y /t'7Vw•" Dare •(
7' WORKCOMPENSATION DECLARATION
I hereby&Bien under penally of perjury as of the following declarations:
1p�rbs and will met nuin a Cerditam of consent m set f-insum fa WmenesCompen-
sadon,as provided(ea by Section 3700 of the Labor Code.roe the performance,of du
weak for which this permit is issued.
L/l r have and will maintain Worhe.Compemadon brou a,as required by Section
3700 of the,LaWr Coda,for the per(mmaue of the weak for which this permit is issued.
My Workees Compensation Insurance carrier and policy number sae:
Cartier. Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This Saban mcd not he completed If he permit Is forauhundmil dolts=(6100)
ser IeSL)
1 mnlfy that In the performance of the work for which his permit is iawd,I shall not
employ any permn in any manerm u becomesub'm to me Worken'ComMnmtion
Laws of Californ F
Applicant
'Oct LICANT:If.aftermaking the CeniOao the
Exemption.dyou should
become subjectinthe Woeh ret Compensation this previsions of do LaWr Cade,you marl
0z forthwith comply with such provisions or this permit shall W deemed revoked.
z O CONMUC1ON LENDING AGENCY
f~ I hereby 4111 NU them its construction[ending agency for he performance of
T1 t•� Ne work for which this permit Is Issued(Sec.3097,Co.C.)
W�Ij Lender',Name
0z LAedeh Addmsar
U O 1 cmti(y that 1 have rad this application and sum that the shave informatI n Is
Y. comm I agree m comply with all city and county ordinances and sum levet relating m
p Wildirilmosmetion,and htmby auhods,rtpeuentstiws or this city m antro upon the
W shave-mendanr4 property for inspection purpmea
gL (We)agree in save,indemnify sad kap harmless th City of Cupertino against
raw to IIaMltdes,judgmeats.costs andexpense which may In any way amve against sato City
U in APPLICANT growing of the DS Oof this D
ANTUNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCg R�EGULQT�Ioo�
�E'O Re-roofs
Sig tum of AppliuMContracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant Or(umm Wilding=opal slow or handle hasardaus maoeial
Us defined by the Cupwdao Municipal Cade.Chapter 9.11.and he Health and Safety
Section 15533()? All roofs shall be inspected prior to any roofing material being installed.
Yu Cb
Will do,applicant or future Wilding occupant same equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hatroom air contaminants u de0ncd by the Bay Am,Air Quality Mangemant all new materials for inspection.
District?
Yes QNu
1 have mad the hamedous materiels requirements under Chapter 6.95 of dm CaWar.
nta Health A SafelyCode,Seedmu 155115.15533 and 25534,1 understand dal if do Wilding
does not cumandy how a tont.that it is my responsibility m notify ted occupant of Ne,
mqulmmenu whm ustW poor moans 0 aCcruncam of Occupancy. Signature Of Applicant Date
Allen u. s 05
owner or sutWened agent Dalt All roof coverings to be Class"B"or better d•J