00100046 CITY OF CUPERTINO '
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
nmLDINGAvwRIS0741 RANDY LA RIR DESIGN INC Proof rN'O' 001.00046
OWNEWSNAME MATSUNAMI GARY H AND KR SOMI 4970 ALLISON PKy APPIJINIIUNsD1'Wi'05/'r"_000
ZONE; (707)452-0123
snNlTnkv No. corvnufL No.
BUILDING PERMITINFO
Z O o, ARCHITECTA6NOINIi1iR:
p ELDC IiCECT PLUMB MECH
ac
ce
�?" LICENSED CON'TRACTOR'S DECLARATION Job Description
m 1 hereby ufrinn that I at licenssd under provisions of Chapter 9(commencing
W wanSmuonnglR)oloiviann3ofthexa,incssatdPmfcssionsCode.andmyliccme CHANGE OUT OF GAS FURNACE AND A/C UNI'
R n C iv in full once and ell cc[.
z nez 6 Licenw Clus Lic.B
ei O w O DareContractor -
W re it.f, ARCHITECT'S UI!CI.ANACION
r;I,On I undersl:uW my'Lunn Mull be Pled a,public record,
tau i 7 p LittnmJ Profcv,ianol
Ore,IE& murp,BUILDERDECLARATIONhO
e = 1 hereby o(Section
Sect that 1 am ewmpt flan the Caoiam, Ally c Lew for the
f-lM which renounce,
(Sett it,
LAR,sines and PmLdcionc Code:epai city or county
`Fe wn ih 4 a ' 'cl- t ( 'her p eJ lith L Yet rat¢ -
d i,w ped t t Wrequires th 1ilua I' M1'rPunta t signed I t nand
ntnl Ip a. II n '. IA e t,r,1 1 (uptee° Sy. Ft. Floor Vulua!IJt367
(u+nmancmg wllh Scmm..7000),11 Division 3lythe i{P,Incss amt I'nfoaioac Code)
I,,that he i,ewatu Ihemfmm and be nasi,fie the alleged evenrdonAny vi mdnn
of Sention7031.5 by any applicant for a permit subjects the applicant to a evil penahy APNOccupancy Type
of not more than rive hundred dof,dollar,S500I', x2040. 00
❑I,as owner of the property,crony employees w'nn wagcws their sole compensation.
will do the work,and the snocmre is nod Intended or nRcreJ fire.sale(Sec.]RU.
Iwaine„unit Pram„ion,Code:The Contractor.License Law doev nm apply to an 303 — R&WAr`4IkktAN1 tAL
d
r pmpc:ty Who,builds or mroo,
pve, Iwo, nowho of.+P.,och work to 1,111
I,,thmofugb his own mnpwycea.prnnamd d,ln,Pon Itnpr,"norn,are III b¢nded 11' 304 — ROUGH ELECTRICAL
olfcmd rot sore.if,latwcvee the hauling or impnwenum I,sold within one year of
,mpletion.the owncelsoilder will have the burden of proving that he did not build or 505 — FINAL ELECTRICAL
improve for purrom of sale.)
508 — FINAL MECHANICAL1.as owner or the source,ame,clmivdy convecting with licensed contractors,to
onetowt the project(Sec.7044,Rosiness and Professions erode:)The Contmcmr's
I icenw Luw docs not apply to an owner or property who hot III,nr Improve,increm.
laid who sonnets fur such projects with a eon rrelt,s) licensed ptlr,mnt ,,the
Cnnnanmai,cnw Luec
C.I on axon'(under Sec. I{k I'C our IM1i,rcn,on ,
owner Date
WORKER'S COMI'MINSATION DECLARATION
I herely spoor andel penalty of peaj rl ane ovine following declaition:
I have end will nairlart or Cenilicata of Consent It self-in,nre ha Worker's
npen,abn, us pmvidcd for by Seetinn 3]041 of the Lahm Onto, for We _
01 have ad
of(he work lin which this Iermil in Issued. -
❑1lase he wits nwinainr,the t Compensation a .,it fr us hick hi by Section
i37Mssue of the ork r Cale,for the pedo rtneec of the xork for which this permit is
issued.Aly N'orAer's Compensation Insurance canier and Policy number are:
(This wi,d I need not be eompkted d a:
carder: policy r.
CI31lr119CACo l” OF Il%IIIONI ON RFROMANO WURKIikS'
Cl1Ml'IiNSA'I'IUN NSUkANCIe /
the pcnnii is for enc hundmJ dollars
i (51pd)0I k".)
I certify that in the perfomonwe of the xork for which this'coni(is issued,1
shall not employ any person in any manner so as to become subject nt the W'orwo,'
Compcnsntion Laws of Califon m,Date
Applicant
of TG APPIA' 1.Il:ride,making Ib,s Ccnd elm oI III cntpaon,you should
bean...,object tome Worker,Ca:olanmlirnt'm..Wrns of nil Labor Calc,you loot
CZ
fonhwim uanply who such pnrvisinn6 or this Permit shall be deemed rcvakul.
G
F' = COtthem I%a consru!NDI NG lending
> Ihcreny which
the therei\a construction Iendin8 agency for perfonnanca
of the work for which this pemtit is owed(SIT,31191.Ci,Cd
5 Q LcMer's Nome
7 z Lender's Address
U O I cenily Ih,u I have read(ho.....plication and,rate ru the above inlorntatlon i,
fi E. a rrcn.I agree m cn,n'I1 wilt all Thy rood countyordinance,and state law,relating
U nt budding collunnetion.and hereby Qutrain reprecoultuves of this city to enter upon
Tal the abovomentioned pmpeny for ingsction purposes.
t4 (We)ogrecu,v,e.indemnify and keep hanks,he Cir,of Cupertino agaa,t
W Iiohilitics,judgme to,costs and c,,po ,which may in any way aacme agxiwt said .Ara
U Z City in coneeyu ore of the goading of this permit r y
Dille
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: �0
SOURCE REGULATIONS.
Signawmar A'plkanVConlmcuu Data Re-root•s
HAZARDOUS NAI iRIAIS DISCLGSUR1i
With,"''(knot m furore buildingmcupant strue or handle harallous 1.116-1 Type of Roof
or,defined red.Cupenino Municipal Code.Chapter 9.12,and the Health and Safety
Core, n 25532(al^
MYmpNo
All roofs shall be inspected prior to any rooting material being installed.
Will rte npplcam or future budding occupant ace cgn4nnemordevmen which If a roof is installed without first obtaining an inspection, I agree to remove
emit haAardnm air ennleft urb as relined by Is,Ray Area Ait Quality Managcmcnl
okernp all new materials for inspection. Applicant understands and will comply with
❑Ye., 0Nlt all non-point source regulations.
I have read the hamNuus materiak requirements under Chapter 6.95 of the
California Iiealih&Safety Leek.Sections 25505,25533 and 25531 1 understand that
d the huilding does rat cu reativ have a tenant,that it is my rosix minility to notify the
ecupan of the requiremnt
es which mu.a be ran prior ut i„aanca of n Cerudo ute of
Occupancy' Signature of Applicant Date,
ser nate All roof coverings to be Class x`13" or better
Ounce aadu+r,ud ason,