04080050 - CITY OF CUPERTWO n �y7a,{
BUILDING DIVISION PERiVIIT �QN � QsL$icR>rG44A1'1TI
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BUILDINGADDRESS: HERITAGECONSTRUCTION AND PERMITNO04080050
972 MCCT.FT,T.AN ED
OWNER'S NAME: PERMIT ISSUE DATE -
KOJI OTSUKA 113622 SARAVIEW DR
E: SANITARY NO. CONTROL NO.
(408) 379-2005
lin
=AENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONIIIAC'IOR'S DECLARATION 1 M sby Arron dw 1 am Iiavcd muter provisions of Chapter 9 immmcndnglob Descriptionction 7010)of Division S of Ne Biomass and Profesmane Code,and my license is
_ ore And eRm ADD 705 SQ.FT.
7��z_ Uceaa Class Lk.g
`i Dom cumnallar
ARCHITECT'S DECLARATION
I understand my plans shall he mored As public mcords 9/22/04 DID NOT PROVIDE COPIES OF COMMENT RESPO
a.np5 Licemed Professional - -
.7 OWNER-BUILDER DECLARATION
I 1 berehy,Affirm that l am exempt from the Continuous Licence Law for the -
0 0 following reason.(Section 7031.5,Busenaa sed Protections Code:Any city Memory
which requires a permit to construct..after.Improve,demnlixb,or repair any nrucluel
Fin prior An its issuance,also requires the applicant for such permit to Bk a signed su nacre :v
< that heislicensed pursuant mthe previsions ofthe CummmrsLicencelaw(Chapter 9 Sq.Ft. Floor Area, Valuation -
zC� (C mmcmingwiLhSallon70DO)of Division3ofmise Business and Profmiam Ca )ur
3 s that he u cwnpt dertfrom and the basis for IM alleged eumpdon.Any violWun of S150000
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN NumberAir
ane Occu T
AM mar than Em hundred dollars(5500). P Y'Type _"
I,As owner of the property.or my employees wide wages as their sole compermadon, Jetrn
will do to work end the suuctum h Artmknde imaRmW for Ask(Sm.7014,Butircu
and Professions Code:The Contractors License Law does not apply to owner of eORVed In IO S
property who bulldsorimpevee thereon.and whodommehwalt himselforthrough his ®� '•�•
own employees.provided thatsech improvements art nal Intended araRered total-If. OP�s
however,the building orimprovementisanld within one yevofcompledon.the owner- - -
builder will have the burden of proving that M did not build or Improve for purpme of
ole.).
I,as owner of the property.am exclusively connecting with licensed continuous to
construct the project(See.7014.Busieuv and Professions Code:)The Cavacta'a Lt. -
came Law docs not apply to an owner of property who builds or Improv daemon,and -who contracts for such pmlecu with Acontrsetam s)liceMed Punnet in We Conuacloes
Lle" w
❑1 aemPt under Set:' C far di n
L
er Da / O
/ lT9C5'C MPENSATION LIECLAM N
I hereby 0 under penalty of peUury ono of the following decimations:
am end will msinlsinaCenxeate ofCamenl to wlf•IMurt for Workers Compere
motion,as provided for by Section 3700 of the labor Code.for the Performance of the .. _
work for which this permit is hoMd.
❑I have and will maintain Worker's Compensation Insurance,ss required by Section .
3700 of the Labor Code,for me performance of the work for which this permit u hosed.
My Workers Compensation Insurance arca and Policy number art:
Cartier. Policy No.:
CER IFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lhhaection need not Mmmplemd Ifft Permit isfmonc hundred dollars($100)
or less.)
1 unify that in the performance of the work for which%is Permit is is and,l shell not
employ any person in any mangier an a in become mbjxt in the Workers'Compemtion
Lavas of California.Data . . ..
APPl1am
NOTICE TO APPLICANT:If.after making this Ccnifleme of Exemption,you Mould
become subject te the Workers Compensation previsions of the Leber Cade.you mum
Oforthwith comply with such provisions or this permit shall be deemed mvaked.
ti CONSTRUCTION LENDING AGENCY
[.r I hereby oBrm that Nemiaa mmuctian biliingagemy for the perfermarce of
a> the work for which this permit is imued(Sec.3097,Civ.C.)
GQ Lenders Name
0.7. Lenders Address
U 0 I certify dist 1 have rad this application and mute that the Ahem Information is
coma I agree to comply with all city and county ordinances and suss laws misting to
0 rV^ Wilding consuumian,and hereby suthodae repmunmim of this city in enter upon the
aMve-mentianed property fm inspection pugmss
y (We)agme m um,indemnify and keep harmlm the City of Cupertino against
„ y Ilabili0exjudpmcm,em a and expeaa which may many way We=agsiML said City
U z In emvegnerce of the 'ng of this Permit. __ -
., APPLICANT U R NDS AND WILL COMPLY WITH ALL NON-POINT Issued by: - Date
OUR ERE S. 2—
sig u Ca
Re-roofs
✓ZARDOUS MATERIALS DISCL m
Type of Roof
WIII the epplicent na(alum building e.Chaptemm mad the
h Health a material
As defined by de Cupertino Muni' I Code.Chapter 9.12,and the HMIN and Safely '
aM,Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.-
❑Ya Nu
Will the applicant or future building oceupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove .
It hmamna'Air conuminanu g(dcMcd by the Bey Arca Air Quality Management all new materials for inspection.
Diankt7 •rWA/
❑Yea No
1 hex mad die hmNtms mterlals mquimmenu under Chaper6.95 of die Califor-
niaHeslthaSafetyCade,Sme=25505,25533and25334.1undenunddwiftbe Wilding
does mel cmrenllyA mans.the It is my Anspnmibilily to Artily the occupant of de
myui)cmcn. w ohms met prier to issuma alfa CCNOcaof uP Signature of Applicant Date
Owns Ault ed agent ate O All roof coverings to be Class"B"or better