03070210 CITY OF CUPERTINO p'^`
BUILDING DIVISION PERMITCON,TRACTR£INFRMATIONI"
1 re
BUILDING ADDRESS: PERMIT NO0 3 O 7 O 2 1 O
.R'S NAME: PERMIT ISSUE DATE
KANEKO OSAMU
ONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
lOp LICENSED CONTRACTOR'S DECLARATION JobDescri Description
u I hereby affirm that 1 am licensed under provisions or Chapter 9(commencing p
ma with Section 711(10)of Division 3 atom Ii d Professions Code,and my license is
.0 HOUSE in full fade on en
iq? LiccnscC � Lic.N✓-'141Br.5 HOUSE CORNER REPAIR . (VEHICLE DAMAGE)
;F Dam --CII ECLr15Y72 5M"`e`q 1AK- CONTRACTOR: CPR SERVICES, -F M
ARCHTTGCTS DECCATATION
1 understand my plans shall N used as public records
Licensed Professional
AUG 2 12003
OWNER-BUILDER DECLARATION
2 q 1 hereby affirm that I am exempt from the Contractors License Law for the
COO rollowing mason.(Section 7031.5,Business and Professions Code:Any cayur count' (p�I��6Jwg�N which requires a permit m construct,alter,improve,demolish,lir repair any svuBcmre
Sesal prior In its issuance.also requires the applicant for such permit to file a signed statement
a—< that be is licensed Dumont to Ne provision of the ComraClOrs Liccnm Law(Chapter 9 Sq. Ft. Floor Area Valua"g00 -
k�a (commencing with Section 7000)of Division 3 of the Business and Praressions Code)ser
$
that he is exempt the efrom and dee basis far Ne alleged exemption.Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of 3(9iMQtQuAc:r00 Occupancy TI e '
not more than Ove handled doll...($500).
p y Jp
❑I,a owner of the property,m my employee with wages As their Sate compenmion,
will do she work.and Ne svucmm is not intended or offered for sale(Sec.7044,Business ggoeoo❑❑ d Ins eCIiOnS
and Profession Codc:The Contractors License Law does not apply to an owner of 101 - FOUNDA'1'1'eJK p
propeny who builds or improves thercon,and whodooe such work himself or drought his
own cmployces,provided that such improvements are not intended reoffered formic.If, 102 — PIERS
however,the building or improvement is sold within one year of completion,the owner
builder will have the burden of proving that u did not Wild or improve for purpose of 103 — UFER
cal`')' 104 - REBAR
01,as owner of the property,am exclusively contracting with licensed contractors to 105 - ANCHOR BOLTS
consumer the project(Sec.7044,Business and Professions Coda:)The Contractor's Lt
cense Law does nor apply to an owner of property who Wilda or improves thereon.and 106 — SEWER & WATER
who contracts for such projects with a contractor(,)licensed pursuant o the Curvatures
License law. 2'02 - UNDERFLOOR PLUMBING
❑I am exempt under Sec. B,4 P C for this lesson 203 - UNDERFLOOR MECHANICAL
r Data 204 - UNDERFLOOR FRAME
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: 205 — UNDERFLOOR INSULATION .
I have and will maintain a Certificate of Consent to sal f-insum for Worker's Compere 301 — ROUGH PLUMBING
station,u provided for by Section 37,)1 of the labor Code,for the performanim of the 302 — TUB & OR SHOWER
work far which thia perms is issued. 303 - ROUGH MECHANICAL
❑1 have and will maintain Workers na
Compensation Insun ,as inquired by Section
3700 of the Labor Cade,for me performance of the work forwhich this permit is issued. 304 — ROUGH ELECTRICAL
My Workers Compensation Insurance eerier and Policy number am: 3 05 — FRAME
c -TAM punto Prucy 925 306 - HOEDOWNS
CERTIFICATEOFEAEMPIO WORKERS'
COMPENSATION INSURANCE 307 INSULATION
(This section need not be Completed if the permit h for one hundred dollars(Ata) 308 — SHEETROCK
lir less.) 309 - EXTERIOR LATH
e ploy thus in the in
panne of the work for which this permit is ivad,I Shall not
employ any person in any manner so As in become subject mus,wortrn'Compenmion 310 — INTERIOR LATH
Laws or Caliromia.Dam 311 - SCRATCH COAT
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should 313 - ROOF NAIL
become subject to the Worker's Compensation provisions of the Labor Code,you man
D roll comply with such Provisions Or this permit shall 4deemedrevoked. 501 — FINAL ELECTRICAL ENERGY
z CONSTRURIONLENDING AGENCY 502 - FINAL PLUMBING ENERGY
I hcmby affirm Nn there is a construction lending agency for the arrormanck of 503 FINAL MECHANICAL ENERGY
1i Ne work fur which this permit Is issued(Sec.3097,Civ.C.)
it q
Lender's 504 504 - FINAL BUILDING ENERGY
D Loodef'Add. 505 - FINAL ELECTRICAL
J O 1 certify Nat 1 have mW this application and sur:that the above information is 506 - GAS TEST
y� corer.I agree to comply with all city and county ordinances and state laws healing 10
JU building construction,and hereby authonna mpresenratims of Nis city m enter upon the FIN PLUMBI G
C above-menriuned property for impeNan piMosea 08 FIN L
:.. (We)agree m save,indemnify and keep harmless the City of Cupertino egaimt
N liabilities,judgments,costs and expenses which may in any way acCrue against said City 5 A
JZ in corset' a of th�f'A
z APPLIC UNDCOMPLY WITH ALL N WPOINT Issued by:5 NG DatE GULA _
7 �� Re-roofs EPT
4f&nat of Applin on1mEm, Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle havardous material
LU defined by the Cori
upMunicipal Code.Chapter 9.13,and the Health and Safety
e.Stolon 2ss32(a)?ertino
❑Ych XNo All roofs shall be inspected prior to any roofing material being installed.
Witt the applicant or future building occupant are equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hazardous air coolant Interest as defined by the Bay Area Air Quality Management all new materials for inspection.
isenct?
0Yes �No
I have he a harandous materials requirements under Chapmr6.95 Orem Califor.
ria HeaM&Saf y ode,Sc no 25505,25533and25534.1 understand d1 irthe building
docs not careen am a m n that it s my export to utility rhe txeupanr of the
require�w eh man IMi its tartars Ceniner�ofo,:P ey. Signature of Applicant Date
Ow er lir suthnrircd agent Date
roof coverings to be Class "B" or better