04120160 (2) CITY OF CUPERTINO -
BUILDING DIVISION PERMIT .iCONTRACTORANFORMATIQN -
BUILDINGADDRESS: HERITAGE CONSTRUCTION AND PERMITNlb4120160
. 21972 MCCLELTAN RQ
OWNER'S NAME: PERMITLgUEDATE
KOJI OTSUKA 113622 SARAVIEW DR 12 /22 /2004
ONE: SANITARY NO. CONOL NO.
(408) 379-2005 TR
ARCHITECT/ENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0 0
LOO LICENSED CONTRACnOR'SDECLARATION
fChap
V C 1 hve6y affirm taut 1 am licensed undo and
Pisioru or Chapter 9 my liecnring Job D¢SCrlp[tOn
tl
no, iwith Section TIXMI)of Division Sof NC Busineasand Profesrioru Code,and myliccnx is
nfnnmscamdeffea TEMP POWER POLE
qz Limmac Class Lk.a
iy� ARCHITECT'S DECLARATION
Da¢ I�ECARATION G�
�3 m i I urgcrsund my pem shall he used a public records
m
a u Liccmed Professional
+05 OWNER-BUILDER DECLARATION (�All
c/
<I 1 hereby affirm that 1 am exempt from the Contractor's License Law for the G /' n
❑a following mason(Section 90 L5,Business and Prefesdom Conk:Any city or county �/ rY,i^ '
;<m� which mquires a Permit m construct,alter,improve,demolish,m repair any structure 4 Y N ,r 3 0 0
_iy prior to its issuance Wan retuire<tbe applicant f.rsuch permit m role a signed statement
ss`e the le is canedpmmam I.the pmviseamthc conuumn Manse Law(Chaptu9 Sq.FC Floor Area � -`J� ,�(� J Valuation
rah (commencing with Section 7W)of Division 3 of the Busincound Professions Code)or
that he is tempt thmef.m and the bases for the alleged cammirdrn.Any violation of GU -
Semon 1031.5 by racy appliam fm a permit mbjecm the appli.t m a Wvil penalty of @ 0 �Onor mom than Rru hundred dollars($500). CCU anC Type
❑I,as owner of the Pmpeny,or my amPloyw with wages as their mlc compeaaton,
will do the work and the structure is not inemmol.,offered ferule(Sec.?O<a,Busimss
and Prefeuioa Coronaries TheCoronariesnot r's License Law dors apply m m an cwoof Required Inspections
p.perty w ho bu ilds or i m proves thereon,and who does such work himself or Nmugh hes
own employ.,provided Nat such improvements arc not intended aa.ffertd formle.If, -
however,the building or impmvemem is to within..year ofcomplction,the owner. - -
Wilde-will hats the burden of proving thm he did nm build or impmvc for purpose of -
silt.).
El 1,as of the property,am exclusively contracting with licensed comramre to
const.t praised(Sec.?Diol,Business and Rafesems.Code:)The C.nuactes's U.
cense Law docs not apply in an owner of property who builds or impress thereon,and.
who contracts for such projects with a comeacmr(s)licensed pursuant m the Cenuactars
Liccoe law.
❑1 exempt unddeerr SSeeec. ,B k P C feaNis moonDate `J{('
ser �OR 'S OMf PEEN$ IIIOOND�.C�CAMTION, � I
i hereby affimh under pemlty of perjury oro of the(ollowin6 dalaratoa:
I hers and will manain a Certificate of Continuo elf-Insure forWorker's Compen- - -
ution,a provided for by Section 37W of the labor Code,for she performance of the
work for which this permit is issued.
❑1 have and will main Wn Worker,Compensation Insurance,a nx rited by Semon371 of of the Labor Code,for dte peRomurme or the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: -
Cartier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section reed not be completed lithe permit is!bunt hundred dollars(SIM)
or kis.)
I cenify that in the perfummuc of the work for which this permit is issued,I shall not
employ any permn in any manner¢At in become subject to the Workers'Compcnsocon
Laws of CWifsmia.Dam
Applicant _
NOTICE TO APPLICANT:If.after making this Certificate of Exemption,you should
become subject in the Worker's Compensation previsions of the Labor Code,you must
.J O forthwith comply with such provisims M this permit that be canted ranked.
z y CONSTRUCTION LENDING AGENCY
[-+ I hOmhy.m.that there is.cum action lamingagency for to pcsfummiumm
Ix^ the work for which this permit is issued(Sec.3097,Civ.C.)
lender's Name
=z Lenderi Address
U C) 1 certify that 1 haw mad Nis appli.don and sore that the above information is
Ice, F-' c0mcL I agree to comply with At city and county on inamss and sum laws mlating in
p V building construction.and hereby aulhone mprescmatvcs of this city m enmr upon the
pro
ahovetmentidgm judgments,
costs
for Sarco sarcoma which
fr-a y (We)agree 1.sacs,indemnify and kcep harmless to City of Comment against
Z in
etijudgmentse cramand expenseswitch may in any way acc.c against cid city 456�
Z inc.rmcgnencc of Nc gmnun6 of Nes Pcsmit.APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: do
Da
SOURCE REGULATIONS.
L �L Re-roofs
namrc a pp icanVComrecmr
HAZARDOUS MATERIALS DISCLOSURE ate Type of Roof
Will the applicant or future Wilding occupant stare orhandlc havamoUs muchal
as defined by the Cupertino Municipal Code,Chapter 9.11,and the Health and Safety
We.Section 35533(x)? All roofs shall be inspected prior to any roofing material being installed.
�Y
Will Nc a finnt.r mem building occupant ati equipment If a roof is installed without first obtaining an inspection,I agree to remove
PP 6 0 y pment m devices which g P
mit hazardous air contaminants a de0ned by the Bay Area Air Quality Management all new materials for inspection.
District?
fB,Ycs /T�
II -
Ihatheus
imouth
vem'ulmaterials requirements unser Chapter 6.95orthcCaliror-
niaHesiN A SafetyCWc,Satione25505,8533 and 25534.1 undersand thmifthe building
Jon not currently hmc a tenant Nat it es my map.nsibitity a Iwfify the occupant of the
rtyuiremcnm hkh mealbemm pnormiuuacc ora Ccrtif`a¢of Occupencp Signature of Applicant Date
Goalie,or author ed agent Dalt All roof coverings to be Class "B"or better
= a Community Development
10300 Torre Avenue
I
Cupertino CA 95014
Telephone(408)777-3228
CITY OF Fax(408)777-3333
SUPEkTINO
Building Department
JOB ADDRESS: " / PERMIT
OWNER'S NAME: C>( Sw((.A PHONE #
GENERAL CONTRACTOR: WCoN FAX #
—
I am not using any subcontractors: �zz�- (�R� 2 Z O
Signature Date
Please check applicable subcontractors and complete the followin information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
7A j
bwner/Contractor Signature Date
CITY OF CUPERTINO
SUE- TEMPPOWER ,tel e o
�CUPEkTINO PERMIT APPLICATION FORM'
APN # / O 0 7 Date:
Building Address: 7 C
2 2 -
Owner's Name: Phone#:
i S �--OCk
Contractor: Heli:{--sp— ri S a5 Phone: License #:
Contact: Phone: Cupertino Business Licebse #:
k I 1j - VZA-N 3 i 5 2�� 2
Building Permit Info:
Elect
Job Description:
Residential Commercial
Cost of Project: 4;
`S'17
•
y. if
1' ab e Fee ID Fee Description Fee Group
BTEMP Temporary Power ELECTRICAL
EPERMITFEE 'Elect. Permit Issuance ELECTRICAL
BUSLIC Business License BUILDING
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