05080200 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT , CONBT„RACTOR,INFORMATIOh
BUILDING ADDRESS: SASHA CUKIC PERMITNOO 508 O 200
21796 STEVENS CREEK BLVD
ER'S NAME: PERMIT ISSUE DATE
SASHA CUKIC 08/22/2005
NE: SANITARY NO. CONTROL NO.
ARCHnECffENGINEER: BUILDING PERMUINFO
BLDG 0 PLUMB 0
�o Zp LICENSED CONTRACTOR'S DECLARATION
8 1 hereby affirm that l am licensed under provaimu of Chapter 9(commencing Job Description
with Section 7011 of Division 3 of the Business and Profession,Code,and my because is
I.full force andarech. REMODEL-ADD BATHRM & REPLACE WINDOW IN
S�� License Clan ue.g MS BEDROOM /RELOCATE KITCHEN
f Dam Contractor
ARCHIECrS DECLARATION
g I understood my plana shall he urA An public retard,
3
is
Licensed Professional
OWNER-BUILDER exempt f DECLARATION
Q 7 1 hereby affirm o n 1 am exempt sass the Contractors Coo License Law for Ibe
OO whichfollowmoron.Permit
7reasur t,alter.and improve.
deron Code:Any city or county
$ which titsWrequires a permit re emWmCl,alcor.Imfor such
de permit
Or trash any umcm=
H Z prior m lls iamnca also partner,
to One previsio o for Contra rmit m masee a signedw(Cha mens
F c (that he comma cingwitPurstion7 the ofDiviomoftheConusinces uconseTaw(Chapter9 Sq.Ft. Floor Area Valu
qq $ that he
(commencing with section 7000)the
basison3 ofta ineamptent.and my
Code)ar
Nn k ts exempt rhertfmm and the bait far the aIle{ed exemption.My violation of
S"Wout 7031.Oum5 by
anihunpplicanta(SSWrmit subjects the applicant in Achill penury of ep effber Occupancy Type
not no� 35716011 . 00 .
ly 1,An,veno of the property,or my employees with sages As their mm compensation,
will do the work.and the stratum is ret intended or offered for sale(Sam.7014,Bwineu Required Inspections
and Profeamss Code:The Contractors Licence Law don not apply m e ns an owner of q p
property who builds components hamor.and whodom,mitworkhimselforthrough his -
Own employees,provided Nat each improvements an,not intended proffered tensile.if,
however,the building or Improvement Is sold within one you of completion,We owner.
builder will haw the burden of proving Nn he did not build or Improve for purpose of
sale.).
❑1,as Owner of the property am exclusively conuscting with 1lceused eoabatee,to
canonical On project(See.7044.Business and Profntlon Cock:)The Conrncmrs u-
ttme law dao not apply to an owner of property who Wild,or improve Norton,and,
who commas fm such projects with conuaetor(q licensed pursuant in the Connectors
License Law.
❑I am exempt uu�nderr!�sea .B B PC for this mann
OR Dam 2
WORK OA 'ENSATION DECLARATION
1 hereby aflim under penalty of perjury ane of the following declandmu:
w and will amman a CerdOnte of Consent to self-insure fm Workers Compel.
,as provided for by Section 37M of the labor Cade.for the perPomanee of the
rk for which this permit is!,seed.
❑ sic 1 baand will maintain Workers Compensation Ineunce,a nrequired by Section
3700 of the labor Code,for the performance of the work for which this pemit is inuW.
My Worker,Compensation Inaunnce carrier and Policy number am:
Center. Poliry,No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(mnsectian reed tet becompleted little pemlt Isforom heradmddollan($100)
or lice.)
1 comfy Nat in Ne performance of the works for which Ni,permit in Island.I shall not
employ any persen In any man&er�y�C Ci abject to the workem CompensNon
Lawa of Califon a.Dam 42 o
Applicant
NOTICE TO APPLICANT:IL after making this Cenincaue of Exemption.you should
became subject an the Workers Compcnatian provision,of the Labor Code,you must
.JO forthwith comply with such provisions at this permit ahsll be decreed mvolmd.
z.~N. CONSTRUCTION LENDING AGENCY
[+ Thereby M.that ft.1.A combustion leading a{cnry far the performance of
> Thr:wark for which this permit is Wuc l(Sec.3097.CO.C.)
QLenders Name
D z lander.Address
U Q 1 ceNfy,that I haw mad this application and sum that IW above informs un is
U,U cam,.I agree to comply with all city and county ordinances and slste laws Palating to
C building convection,and hereby author!=tepresentativees of dill city to enter uPW the
W ahove-mentioned property for inspection purposes
Ff+ (We)agee in sew,indemnify and keep humle i Ne City of Cupertino agaimt
`en IlabilNn,judgmenn.calls and expensees whi may in any way amus alai,said City
APPLICANTIncor UNDERAenceafthict NDf AND ILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIO
8 Z Re-roofs
Signmure of Appli n or Dem
HA2ARDOU ATERIALS DISCLOSURE Type of Roof
Willy t applicant or future bulling omupaptnorc at handle health and Safety 1=,
Oned by de Cupertino Municipal Cade.Chapter 9.11.and IW Health and safety
Section 25532.)7 All roofs shall be inspected prior to any roofing material being installed.
❑Yrs ON.
Will Ne applicant or comm building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hamims air m=inanu a del ned by the Bay Ana Air Quality Management all new materials for inspection.
OO
❑Ycf ❑Nu
1 have mad the hnardous materialsroquimments under Chapwr6.95 ofthe Califor.
colth At Safctycole,5' dam 25505.25533 and 23534.Iundmnand Nuifde Wilding
Imre cummly ow Carl,that It la my meporninilhy m Wdfy the o supant Of the
mmenAt WCwmeofaCWnc,teofOccupancy Signature of Applicant Date
���� All roof coverings to be Class"B"or better
ro and agent Dam
L