01090081 CITY OF CUPERTINO
BUILDING DIVISION PERMIT ''CONTRACTOR`INFORMATION:
BUILDING ADDRESS: I PERMIT NO.
21623 CASTLETON ST HIGASHIUCHI JON M AND DO CAS Y01090081
OWNER'S NAME: APPLICATION SUB DATE
HIGASHIUCHI JON M AND DORCAS Y 09/20/2001
PHONE' SANITARY NO. CONTROL NO.
❑O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
.{p BLDG ELECT' PLUMB MECH
y< - CJ LJ 1 � L=_1
LICENSED CONTRACT'OR'S DECLARATION
5 H 3 Job Description
Z�❑ I hereby 3)of Thal I am licensed under provisions of Chapter 9(commencing
wH is infilforceandofeel. on3ofNeBosinessandProfessionxCode.vndmylicense INSTALL GAS INSERT.
Y 16 is infailforce and effect.
Oi License Class Lie.p
u y Dale
ARCHITECr'S DECLARATION
O.'i 1 understand my plum shall be used as public records
i r C
n�O O Licensed Professionvl �
OWNER-BUILDER DECLARATION
u' on 1 hereby affirm thin 1 am exempt from the Corminum's License Law for the
y
C Z Q
following (Set ]W I S Business In'o f s Ions Code e An,city or county
❑
which requires a permit on con.arum ,alter.improve.demolish, par any to et 2 0
-mimut a s e els «qu theN ilio of
hpetmu is La (Chapter
Cha t - --- ._.. __.. -...... ... ..
Nat ha 'I' provisions .. .`._._. . -...... .... .._..
sndpurs a n the p ism fah C 1 ns ma to (Chapin 9 r' a t'" xx uv V Ila
(emthe Is
Section and the basis
or t the BusinessmWPmf sCode) k',p,QT � F3.�®'1 ( °P �,,..t f�l+t Y'
or shat he I exempt therefrom and the tr s s for the alleged xemptiod Any violation
of Section]031.5 by any applicant for a permit subjetts the applicant to a civil penalty
.four noremanfive hundred dollars(S500), 30JA N§ 9['} li PLUMBIN ir Occupancy Type
asw rofnhe properly,or my employees with wages as their sole compensation,
will do the work,and the structure is nor intended or offered for sale(Sec.70 ,
Business and Professions Code:The Continuum's License Law does not apply to an 304 - ROUGH EJM¢fltRdYtl3ldect10115
orof property Who builds or improves thereon,and who does such work himself
throughv ghis own employees.provided that such improvements are not intended or 505 - FINAL ELECTRICAL
safli for sale:If,however,the buildingor improvement --
ofpmvisaoldwldllnnneyearof 507 - FINAL PLUMBING
completion,the owner-builder will have Ne burden of proving that he did not build ar
mpmef prposeof`ale,) 508 - FINAL MECHANICAL
� _ . .
s o e le property,am exduicas a d contracting profession, licensede Cita uca 'a -
on ns t a pr j n(Sec ]to a ownBtusier a and ertywhbCode)The Conthemon, V
License Law does not apply a an owner of property who builds or Improves thereon, {
:S .andwbo contacts for inch.proje<u with a comamor(s)licensed.porsuam to the
Contractors License La
°ISee
a BAPCfor thsmason iC"1
O n<
0 KER S COMPENSATION DECLARATION
by affrrn under penalty of perjury one,of the following declarations:
° I he.mat''will maintain a Cenifieaie of Conient'to self-imum for Wolkera
Compensation, as provided for by Section 37W of the Labor Code, for she
pelf emlance'of the work for which this permit is issued. .
°1 have and will maintain Workers Compensation Insurance,is required by Section
37M of she Labor Code,for Ne,performance of the'work for which this permit is
rssutl MYWrionIsuacec APotcY be re.
_. .... .. ..._..� ..-.....
Carne,Y i I'IL'obc No. „I
COMPENSATION ION7MO WpRKER �. d S 1 r ! i is t PJe firY s
CERTIFlCATION OE EXEM�NSURAOCE _ -
q l
fissec[ion need na ltd completed if the pemlit is for one hundred dollars
(91 W)or, lass.) r '
Wily Nasi Na Person in anynpe f th ark for which ub petro[a is.tied I
shall not employ any fCm any manner seas to become subject to the Workers,
Comicant on Lews of Celifomie.Date”Appl
NOTICm _ gths - . .,. .. .._. .... . .. .... _._. ._..
NOTICE TO APPLICANT If.after mak Certificate fExemption,you should
beccome,mo,et ya
wthe WorkersCompensation provisions of the Leber Code,you must I
Z
O forth N ply pith ugh previsions or this ce I rout shell be deemed revoked
CONSTRUCTION LENDING AGENCY -
.a I hereby affirm that there is aconstruction lending agency for she perforin se
of the work for which this permit is issued(Sec 309] Civ.C J
t4�.Q 'Londe Name"..... __, . ...,.
V.C' c I comfy.that I have read this application and state that the above informal on is
correct..I agree to comply with all city and county ordinances and state laws relining
ro building conswction,and hereby uutlamim representatives ofthia city to enter upon
dei tat
the above-mentioned property for inspection purposes.. _. _
As (W) gree m m e;Indemnify and keep harmless the City f C perino against
liabilities,judgments,costs and expenses which may in any way weme against said
U;z 'Cryin consequence of the granting of the perms
APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT
' SOURCE REGULATIONS "'.I Issued by: Date
Signs tore fAp�bc onlContractor 11
HAZARDOUSMATERIALS DISCLOSURE "��'Dane. +.�
- Re-roofs
Cask.s coon 2.Ss32 t f m e bu Id n6 Ott p t st re or helMl hazallous mvenal. "Type of Roof.. - ...-..
WIIN pylic
v defined by N Capmm M pal C d Chapter 912,and Ne Health and Safety 1 '
If a roof is installed without first obtain) 1
lq a CI jV 151�`ll a ti y4 p
"' °Y a °" ` t All roofs shall be ins ected.pnor,to any,roofing material being installed.__ .
1 WBl the app) e ."Future building Occupant equipment devices which t 'ng a0 lnSpeCtlOn;'I ag1'0e IO'I'emOVe
em t h b a r conte mints az defined by h 'Bay Area A r Qoably Manugemem ,
all new materials for inspection._Applicant understands and will comply with
❑Ys . ., or?n all non-point source regulations:;. . _
I have,read the hautdous materials regmremenns undo Ch'plet 6.95.of the
6.1n 25505 25533 and 25534.1 ursta
ndend that `
If the building does not currently M1 tenant that it is my responsibility to notify the
fo e Health&gerety Code,Senio
occopani of Ne requirements which must be et poor a iss n e'of a Certificate of
oq npan`y, Signature of Applicant. Date
1
Owner ant wooed again' J11 Date All roof coverings to be Class,"B"or,betier
._ _ OFFICE