04120153 CITYOFCUPERTINOa@ '�' yya
BUILDING DIVISION PERMIT- �1`I?1 OTOR NF �• _ .- _
. ' BUILDING ADDRESS: - PERMITN004120153
22205 VIA C)kMINO CT
OWNER'S NAME: PERMIT ISSUE DATE
GEORGE & ELAINE KITAGAWA SANITARY NO. CONTROL NO,
E:
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBm! o
' MECH
t
00 LICENSED CONTRACTOR'S DECLARATION _ JOb DeSCiI tlOn '- -
0 I homey affirm Net 1 mo demoted under provisions or Chapter 9(commencing p
with Section 1000)of Division 3 of the Busimss me Professor.Oxm,md my license i,
mfull force and effmL REVISED KITCHEN PLANS
uem02CClass c u,ctar IN HOUSE ONLY-ORIG PERMIT #04090038
ARCHITECT'S DECLARATION
1 understand my plana shell he used as public mend,
3 a Lkensed Reread...I
a'0 OWNER-BUILDER DECLARATION
4 1 hereby affirm that 1 am exempt from the Contractors License Lew for the
O O following mason.(Sudan 7031.5,Resumes and Pmfcaeiom Cade:Any city or county
$tar which mquirea a permit to canwuet.altar,improve,dcam W.or nomir any structure -
fZY prior in its ismance,alus requires[be applicant lorsuch permit in file a signal summer, .. •{ -
themheisliccnsedpunuan,tatimpmvisiomofiheConwcmr',Llmnseiaw(chapmr9 Sq.Ft. Floor Area - Valuation
$ (commencingwiden Smtfonlandth basisfr of theBarl exond...My r,CsMe)or
io u exempt Ianrerrom and me bum(or the cts the emmant to a civ l penalty
of - -
setimlBvsbTam•vpaeantfar.Peppemeemthe.ppliantm,emBpn.nrer - -APNNumber - OccupancyType -
not mare than five hundred dollen(55001. 32646015 . 00
❑I.as owner of the property,ar my employee,with wagas a their mic compensation. _
will do the work,and ree,vuctum u act intended or offered far ads(Sm.7044,Business Required Inspections
and Professions Code The Contractors License Law Boas not apply to,n awmr of - q p
pmpeny who builds orimproves therced.and whodoaawl,work himselforthrough his - -
own employees,provided that such improvements are not intended oro@red for We.If, -
hawevm,Nebuildingorimpmsemmtissold MB inarcoarofmmpleuon,sheowmr-
Wilder will have dm burden of proving that he did no,Mid or improve for purpose of
aJISJ.
co 1,u owner of ct Sec.70R,m adusivoly and contracting with licensedmurmuacontractors;U. -
come La the project(See.a an Business end ny who Wilds
Code:)The Convamon, rad
cense Lawmsfnot apply jetsowner ith. ofproperty who buildsormat to dsthereon,and - -
Lwho convacu far such projects with a convmtortU licensed punuent m diecontractor" -.
License law., y
I.ase y5lder Sec ,B h P C far this reason ..
as
WOR S COM N 10 ECLAR ON -
Ihembyaffr under penalty of perjury one of the faliewinghdantions:
I have and will maintain a Certificate of Consent to self-insure for Worker's Comped. -
cation,as pmvidcd f.by Secdon 3700 of the Tabor Code,for the Performance of the --
work for which this permit is issued.
rl 1 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of Ne labor Code,for the performance of the work for which Nis permit is issued. -
My Workers Compensation Insurance carrier and Policy number ase: -
Cartier. Policy Na.: -
CERfIFlCATEOFEKEMPIONFROM WORKERS'
COMPENSATION INSURANCE
(This smmr,recd not he com pleted i f the permit is rat o.h undred dollars($10m,
or leas.)
1 certify that in me performance of me work for which this permit i,issued,I shall no,
employ any paten in any mapper m as to become subject to the Workcss Compensation .. .. -
Laws of Califomia.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption.you should
become subject in the Worker',Compensation provisions of the Labor Crile,yen most
Q O forthwith comply with such provisions or this parent shall M deemed m Mate.
z" CONSTRUCTION LENDING AGENCY
[r 4 I hereby affirm that mere I.a ronsvuctim lcndinpgcmy fake perfurmanm rf
(L'> the work far which this permit is issued(Sec.3(191.Cit.C.)
A Lenders Nun.
Q z lenders Address
U Q 1 certify that r have reed Nis application aM sum that the be. relatinto
wilds I agree m comply with all city and county ordinances, su
and m laws relating
e
Q iC•J^ building construction,sad hereby euthmiae¢psnenutivu of this city to cnmrupnn the
W shave-(W)Agre to savc for inspection keep a.
G
(We)agree to ave,indemnify and keep yinhandles,the City of agaimno against
UZ incoisequen a shewsv,ngaexperares this perall. may in any way accrue agaWuaid City
U z A consequence of me granting of this D W Il. i
^ OURC NOERSTA OS ND WILL COMPLY WITH ALL NON-POINT Issued by: . Date
SOURC CATIONS (,a� O
// if Re-roofs
ig surto A pli a guar Dam
AZARDOUS E0.1AL5 DIS LOSURE Type of Roof
Will the loam or future building compact store or handle haasdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532p11
YeAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or i mrbuilding occupant um equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
It ha❑raNus us air contaminants as;defined by me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes t` +a
I have read the lows ..dials mquimnxnts under Chapter 6.95of the Califor.
nix Health.&S�Ia Codc,Satio.25505.25533 and 25534,1 undcmmnd mat ifthe building
does nom cu n(1 hovea tend,me t a my responsibility m noddy the occupant or the ,
rtyuirtmcn nmuubc issuan«af, rificateora pansy Signature of Applicant Date
kv 0 rremnn v. ret / at0 All roof coverings to be Class"B"or better
CITYOFCUPERTINOa@ '�' yya
BUILDING DIVISION PERMIT- �1`I?1 OTOR NF �• _ .- _
. ' BUILDING ADDRESS: - PERMITN004120153
22205 VIA C)kMINO CT
OWNER'S NAME: PERMIT ISSUE DATE
GEORGE & ELAINE KITAGAWA SANITARY NO. CONTROL NO,
E:
ARCHITECffENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMBm! o
' MECH
t
00 LICENSED CONTRACTOR'S DECLARATION _ JOb DeSCiI tlOn '- -
0 I homey affirm Net 1 mo demoted under provisions or Chapter 9(commencing p
with Section 1000)of Division 3 of the Busimss me Professor.Oxm,md my license i,
mfull force and effmL REVISED KITCHEN PLANS
uem02CClass c u,ctar IN HOUSE ONLY-ORIG PERMIT #04090038
ARCHITECT'S DECLARATION
1 understand my plana shell he used as public mend,
3 a Lkensed Reread...I
a'0 OWNER-BUILDER DECLARATION
4 1 hereby affirm that 1 am exempt from the Contractors License Lew for the
O O following mason.(Sudan 7031.5,Resumes and Pmfcaeiom Cade:Any city or county
$tar which mquirea a permit to canwuet.altar,improve,dcam W.or nomir any structure -
fZY prior in its ismance,alus requires[be applicant lorsuch permit in file a signal summer, .. •{ -
themheisliccnsedpunuan,tatimpmvisiomofiheConwcmr',Llmnseiaw(chapmr9 Sq.Ft. Floor Area - Valuation
$ (commencingwiden Smtfonlandth basisfr of theBarl exond...My r,CsMe)or
io u exempt Ianrerrom and me bum(or the cts the emmant to a civ l penalty
of - -
setimlBvsbTam•vpaeantfar.Peppemeemthe.ppliantm,emBpn.nrer - -APNNumber - OccupancyType -
not mare than five hundred dollen(55001. 32646015 . 00
❑I.as owner of the property,ar my employee,with wagas a their mic compensation. _
will do the work,and ree,vuctum u act intended or offered far ads(Sm.7044,Business Required Inspections
and Professions Code The Contractors License Law Boas not apply to,n awmr of - q p
pmpeny who builds orimproves therced.and whodoaawl,work himselforthrough his - -
own employees,provided that such improvements are not intended oro@red for We.If, -
hawevm,Nebuildingorimpmsemmtissold MB inarcoarofmmpleuon,sheowmr-
Wilder will have dm burden of proving that he did no,Mid or improve for purpose of
aJISJ.
co 1,u owner of ct Sec.70R,m adusivoly and contracting with licensedmurmuacontractors;U. -
come La the project(See.a an Business end ny who Wilds
Code:)The Convamon, rad
cense Lawmsfnot apply jetsowner ith. ofproperty who buildsormat to dsthereon,and - -
Lwho convacu far such projects with a convmtortU licensed punuent m diecontractor" -.
License law., y
I.ase y5lder Sec ,B h P C far this reason ..
as
WOR S COM N 10 ECLAR ON -
Ihembyaffr under penalty of perjury one of the faliewinghdantions:
I have and will maintain a Certificate of Consent to self-insure for Worker's Comped. -
cation,as pmvidcd f.by Secdon 3700 of the Tabor Code,for the Performance of the --
work for which this permit is issued.
rl 1 have and will maintain Worker's Compensation Insurance,as required by Section
3100 of Ne labor Code,for the performance of the work for which Nis permit is issued. -
My Workers Compensation Insurance carrier and Policy number ase: -
Cartier. Policy Na.: -
CERfIFlCATEOFEKEMPIONFROM WORKERS'
COMPENSATION INSURANCE
(This smmr,recd not he com pleted i f the permit is rat o.h undred dollars($10m,
or leas.)
1 certify that in me performance of me work for which this permit i,issued,I shall no,
employ any paten in any mapper m as to become subject to the Workcss Compensation .. .. -
Laws of Califomia.Dem
Applicant
NOTICE TO APPLICANT:If,after making this Ccnificate of Exemption.you should
become subject in the Worker',Compensation provisions of the Labor Crile,yen most
Q O forthwith comply with such provisions or this parent shall M deemed m Mate.
z" CONSTRUCTION LENDING AGENCY
[r 4 I hereby affirm that mere I.a ronsvuctim lcndinpgcmy fake perfurmanm rf
(L'> the work far which this permit is issued(Sec.3(191.Cit.C.)
A Lenders Nun.
Q z lenders Address
U Q 1 certify that r have reed Nis application aM sum that the be. relatinto
wilds I agree m comply with all city and county ordinances, su
and m laws relating
e
Q iC•J^ building construction,sad hereby euthmiae¢psnenutivu of this city to cnmrupnn the
W shave-(W)Agre to savc for inspection keep a.
G
(We)agree to ave,indemnify and keep yinhandles,the City of agaimno against
UZ incoisequen a shewsv,ngaexperares this perall. may in any way accrue agaWuaid City
U z A consequence of me granting of this D W Il. i
^ OURC NOERSTA OS ND WILL COMPLY WITH ALL NON-POINT Issued by: . Date
SOURC CATIONS (,a� O
// if Re-roofs
ig surto A pli a guar Dam
AZARDOUS E0.1AL5 DIS LOSURE Type of Roof
Will the loam or future building compact store or handle haasdous material
as defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Section 25532p11
YeAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or i mrbuilding occupant um equipment or devices,which If a roof is installed without first obtaining an inspection,I agree to remove
It ha❑raNus us air contaminants as;defined by me Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes t` +a
I have read the lows ..dials mquimnxnts under Chapter 6.95of the Califor.
nix Health.&S�Ia Codc,Satio.25505.25533 and 25534,1 undcmmnd mat ifthe building
does nom cu n(1 hovea tend,me t a my responsibility m noddy the occupant or the ,
rtyuirtmcn nmuubc issuan«af, rificateora pansy Signature of Applicant Date
kv 0 rremnn v. ret / at0 All roof coverings to be Class"B"or better