03010081 CITY OF CUPERTINO Y 'sem YYn/i/'Tn -a 3 W
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION
BUILDING ADDRESS: PERMITNO.
21721 SANTA BELLA PL 03010081
OWNER'S NAME: APPLICATION SUB DATE
ROBERT SHINAGANA 01/14/2003
LONG: SANITARY NO. CONTROL.NO.
ARCHHECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Oa LICENSEDCONTRACTOR'SDECLARATION Job Description
mm F e hereby j yfH that 1 am licensed under provisions of Chapter Y(commencing p
<i with Section 1. of Dry con of the Bus unJ Professions Cale.anJ mylimne it
_Mii�s, infnllfnn dJrre � GROUND OUTLETS/SUBPANEL IN GARAGE/FAN BOXES
ZOY? License Cl If
Lic.n
P0ZFO F],W Cray, ' r
F /" ARCHITECT S CLARAITON
-ay I understand my plans shall M used as public records
aaepaV
W LL O I,iccned l'nnlc.nnnul
OWNER-BUILDIiR DECLARATION
WX 1 hereby affirm Nm that am exempt frothe Contractor's License Law for the
,,a:00O following reaon.(Section1031.5,Business and Professions Code:Any city or county
2� which requires a permit m construct.alter,improve.demolish,or tepid,any nmctrm
prior to its issuance,also requites the applicant for such permit to rile a signed statement
m< that he is livenedu
pursuant Ne provisions of the Contractors License Law(Chapter 9 Sq. Ft. Floor Area $1 WhIatlon
SFS (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
nsy — that he Is exempt themtrom and Ne basis for Be,alleged exemption.Any violation of
Section 7131.5 by any applicmt fora permit subjecu the applicanno a civil penalty of
not more than fits,hundred dollar($500). be Occupancy Type
❑1,u owner of the property,or my employees with wages m their sole compensation,
will do the work,and the stmetu ,is not intended or offered for sale(Sm.7046,Business ±193 TJFBR ,$ppssyry�t�Sy�g[
and Pmfcasions Code:The Contractor's License Law does not apply to an owner of 304 - ROUGH IFIStC'ZTC.L l:H tions
property who builds or improves thereon,and who does such work himself or through his
own employees,provided tha"rich improvements are not intended or offend for sele.If, SOS — FINAL ELECTRICAL
however.Ne building or improvement is sold within one year of completion,the mini
builder will have the burden of proving Nat he did not Wild or improve for purpose of
sale.).
❑I.as owner of the property,am exclusively contracting with licensed contractors to FINALED
consumer the project lice.7040,6aineaa and Professions Code:)The Contractors Li.
cents law docs not apply to an owner of propsny who Wilds or improv thereon,and
who conu
tracts for such projects with a commented licensed pursuant the Contractors `
License Law.
0 I am exempt under Sec. ,B&PC for this redrn 2rTJ 2003
JAN
Owner Da
WORKER'S COMPENSATION DECLARATION BUILDING
I hereby affirm under penalty of perjury one of the following dMarations:
I have and will maintain aCer ifcate of Consent act-hasute for Wofkeri Compen=
anion,as provided for by Section 3711 of the tabor Cntle,for Ne pe,fonnantt of the
work for which this permit is issued.
❑I have and will maintain Workers Compensation Insurance,a required by Section
371)of Ne labor Code,for the performance of Ne work for which this permit is issued.
My Worke�r�s Cl1�mpenpsation lvsumnsa,n,ricr end�Puli/cy number are:
C her: LAbt T�Q•Wili'\'� Poi go.: �- DO 16
CERTIFICA- TE�OFG Ed410 ROM WORKERS'
COMPENSATION INSURANCE
(This section need not Mcompleted if the permit is forone hundred dollars DIM)
or less.)
I verily that in the performance of the work lin which this permit is issued,1 shall not
employ any person in any manner so as to become subject o the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICAT:IL after making this Cenificme of Exemption,you should
become subject to the Workers Compensation provisions of the labor Codes,you muss
OO forthwith comply with such provisions or this permit shall M accused revoked.
Z y CONSTRUCTION LENDING AGENCY
(� I hereby affirm Nat there is a construction lending agency for the xriormmtt of
the work lot which this permit is imand(Sec.3097,Civ.C.)
6Wi Q Under's Name
z Lender's Address
U O 1 certify that 1 have read this application and state that the above in[ermation is
Iia f" cored.1 agree to comply with all city and county ordinances and state laws relating it,
0 U building construction,and hereby authorize representatives of this city to enter upon the
ahnvo(W)afire propene for inspection keep hs.
gy liabilities,judgments,
agree to save,indemnify and keep harmless the City a against against
UZ in
egjnce ofu,coarsing expenses Kormi, may inany way attmc against mid City I/
V z A APPLICANT
of granting of this pct mit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NDNPOINT Issued by: Dale
SOURCE REG CATIONS.
Re-roofs
gnmure of PN1eaHAZARDOUS MATERIALS DISCLOSURE Type Of Roof
Will the applicant or futon building umaturnt store.,handle ha/ardous material
as defined by the Capentnn Municipal Code,Chapter 9.13,and the Health and Safety
Code,Section 25532of? All roofs shall be inspected prior to any roofing material being installed.
D Ye. [�n
Will the applicant or future building occupant use equip mentordevices which If a roof is installed without first obtaining an inspection, I agree to remove
•mit hummous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District/
❑Yes i]1No
1 have read the haallors masrials requirements rack,Chapin,6,95 of the Cubic,
nix IRalth&Safety Cede,Sections 25505,25533 and 255M,1 anokruan iftM Wilding
dues not currently We a e,mnL ohm it is my responsibility to notify tM of tM
requirements whihmuu Mmct br to issuance of a Certificate ofomurpam Signature of Applicant Date
cr or am rind.,car All roof coverings to be Class "B" or better