05120026 CITY OF CUPERTINO
BUILDING DIVISION PERMIT hOIVsTRAC'T0RNF'4RMAT,ION:
Bu1LDINGADDRESS: CHEROKEE CONTRACTING CO. PERMIT NO.05120026
898 FERNGROVE DR
OW NER'S NAME: PERMIT ISSUE DATE
TOSHIHIRO MICHIHIRA 356 MATHEW STEET 12/06/2005
ONE: SANITARY NO. CONTROL NO.
(408) 727-9850
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O !�
30o LICENSED CONTRACTOR'S DECLARATION
L1 hereby affirm that C` lS IiauM under provisions of Chapter 9(commencing
withSe
Section 7010)or Division 3dsc ofBusiness ash Professions Code.and my licatse is
n� intens(area and flea 4" LATERAL C/O
O 2 License Clut I s S I.ie.
Date 17 1 r_ Conuxwr R, IG N
ARCHITECTS DECLARATION
�� lund.rwnd my Pons elWl besued sspublic records (y(�,Jn{///�J /jam 1 AS�
g Licensed Professilana
s� OWNER-BUILDER DECLARATION
1 hemhy.furan Nal I am exempt from the Contravenes License Law for use
p O following reason.(Section 7031.5,Business and Profession Cade:My city or county
E$ which requires a permit W construct,ausr.Mprow,demolish,or repair any structure $3 0 0 0'
prioress its iasuaneo,Alm requires the applicant res such permit tonic a algmdstsumsnt
gFp< thatheislicensedpursuanttotheprevisionoftheConnector',LkenmLaw(Chapter9 Sq.Ft.Floor Area Valuation
ds (commencing with Section 7000)of Division 3 of the Buina194nd Professions Cod.)or
that be Is emmpt thcrefmm and the basis for the Alleged exemption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant W a civil penalty of r Occupancy Type
not mom than Ove hundred dollars(5500).
0 1.as ownu of the property,ar my employees with wages As disco sale compensation,
will do the wank,and the manure 4 trot intended orBusinessd for sale(Sec.7044.Business
and Proresslont Code:The Contsacmrt License Law docs ret apply W an owner of
Required Inspections
properly who bullus sir improve innocent.and who does such weak hi selfor through his
awn amployaea,provided Nn such imp nvemants ire trot Intended or offered fro nit.If.
however.the building or improvement is mid witmn an year of cmnplema.the awrcr-
buiWu win have the WNan Of proving Out W din not MW sir Improve for purpose of
❑I,As Owner of the property,am emluively,converting with IkemeE Commus n In
construct the pmject(Sec.7044,Business and PrefeWam Code:)TW Cantrecroes Li-
come Law docs not apply ro an Owner of pmpenymito Wild,or Improve thereon,and,
who contracts Tor such plainest with a contractor(s)licensed pursuant to due Convaetoes
License Law.
❑1 am esempt under Sec. .B k P C for this mama
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perarry am of the following declando c:
I banned will maintain ACerificeu of Consent W self-insure far warke'sCompan-
ssdon,u provided ran by Section 3700 of the Labor Cade.for tins performanca of dm
work for which this permit it issued.
❑1 ban and will maintain Worker's Compensation Insurance,as required by Smion
3700 of the labor Coda,far tin performance of the work for which,this permit 4 issued.
artan
MyW t a1m1parsam.Insurance ranter d Policy numbeti
r c:
Cans 41•+a Policy No.: O
CERTIFICATEOF CEMPIIONFROMWORKERS
COMPENSATION INSURANCE
(This section need notbecompleteti Him permit lafmaoc huMuddalTats($100)
or inn.)
I certify that In the performance of the work for which this Permit 4luued,I shall not
employ any person In any mannersu as An become subject to the Worken'Compenution .
Lawa of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption,you should
become subject ro the Worker's Compensation provisions of the labor Cods,you must
0 0 forlwiN comply with such provisions or this permit"I beAssumeddmed revoked.
Z'-' EN
CONSTRUCTION LENDING AGENCY
[+� I Wmby affirm duObera4acnnrtnction hndingagcncy,forum rcrfarma,el'
rLr7 the work for which this permit 4 added(Sec.Mal.Civ.C.)
a Q
Lames Name
w`3 z Icnd.et Address
U Q I certify that I have read this application and sum that the allow information 4
U.F caneck i AIM Id comply with all city and county ordinances and mm laws relating to
0 C.) building construction,and hereby authorise repreneonives or this city to enter upon disc
W shove-menti oned property for impaction Purposes
(We)agree to gave,indemnify and keep harmless the City of Cupertino against
H Ilabilides.judgments.costs and expenses which may In any way accrue against said City
t.)2 in consequence of the graving of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S44szo Date
SOU RE ULA'r�ONS.;c-j
5 g_ A 9 f Z�645- Re-roofs
Stgnatureol'Appliun onnamr Date
HAZARDOUS IALS DISCLOSURE Type of Roof
Will disc applicant u reuse Wilding occupant stem Or handle basardau material
u d."C by the Cu An
n Municipal Cod..Chapter 9.11.and the Health and Safety
ale.SCNan 33331(x)7
❑Ym —/ All roofs shall be inspected prior to any roofing material being installed.
[7NO
Will este applicant or future Wilding occupant um equipment or devicca which If a roof is installed without first obtaining an inspection,I agree to remove
It hcxardnus Air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
4tric17 —''
❑Yds LUpro
I hoe mad the WaaNnmmscriais requirements under Chap cO6.95 often Callfor.
fila Hcolthh Safuy Cods,Sectio a 5N15,25733 and 25534.1 untknund WeiNsc Wilding
dant t currently how a unset,that his my responsibility m notify du occupant or the
req cn which uubemet 'muiuuancoofaCcNOcaua`OcYpancY Signature of Applicant Date
owner or Authorized gent I Data All roof coverings to be Class"B"or better
Community Development
aClOF
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
�UPERTINO
Buil din De artment
JOB ADDRESS' u PERMIT#
OWNER'S NAME: i 20 /c ' I, "ZA, I PHONE #Z S 7 U al B
GENERAL CONTRACTOR: � FAX #
I am not using any subcontractors: b =� � ✓V •l�-L 2 (c�o S .
Signature Date
Please check applicable subcontractors and complete the followinginformation:
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
< eel(,
Owner/Contractor gnature�— Date
CITY OF CUPERTINO 2
C`�� I' REPIPE/SEWERS/MAIN SERVICE OS Z
� OF
CUPERTINO PERMIT APPLICATION FORM
APN # 7 -7of G, Z., /Z_ u O�
Bu' din Address:
0 is Name: Phone#:
w6lizo ,/vb—
C nactor: h License #:
Contac_. Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb
Jobpti ^ r U n ^^
Residential `t Commercial ❑
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Pipmg System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i e of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
151 n,.l
BUSLIC Business License BUILDING
322
S-7. 1J