02060081 (4) CIT.-OF CUPERTINo. 'CONTRACTOR.INFORMATION:. .
-.�'BIUD.DING DIVISION' , PERMIT
iBU1LDINGADDRESS:..
. .. ... _ iPERMIT NO.
v r .8141 .PARK_.VILLA CL 1. . . ---- . j� ' 1'."'"02060081
'OWNER'S NAME: '- -' - - --- - APPLICATION SUB DATE -
KAZUKO' HAYAMA 06/13/2002
2{ - rHONE: SANITARY NO. CONTROL NO.
L_l
w,Q p ARCHITECVENGINEER: - BUILDING PERMIT INFO
r w - BLDG ELECT PLUMB MECH
a 2 ' LLD LJ
Z' LICENSED CONTRACT'OR'S DECLARATION
i
= I hereby affirm that 1 am licensed under provision[of Chapter 9(rommencing Job Description
6 � with Section 7")of Division 3 of the Business and Ponfiessions Code.and my license KITCHEN REMODEL
is in fan to.and e 5 3
License Class a_ Lica
P1slIALE®
'O a Dee Contrvcam
1 OFir - AKCHilhUl S DECLARA ON'
,0 5 1 undenmad or,plans shall be used as public memos
}
I O o LiccnsedPrafusional DEC 1 8.2002 ..
' e OWNER-BUILDER DECIARATION ,
vi 1 hereby affirm that I am exempt from the Contractor's License Law for the
t? following mxwn.(Section 7031.5.Baalness and Professions Code:Any city or county BUILDING .$63000
E F C »h ch em 'rc a permit to .wn alcor.improve.demolish omiomicron,r repair any sctu
for r r mice also req theapplicant f such p<nrut m fl a s gn&I[tatcmcm - — -- -- - -
had he licensed prt a uoth midooms,of,heCaroni Ln Lan,IChapmr9, f $$aj�F pr,1 r,,F Valuation
(can c y the t 7000)ofD - J fth Business and Pofgxi Cale) - •� p' kJ t7r U.V,��,I• a.�[E e '
w that he is cxe apt therefrom and thebasis for the alleged commptton Any violation - - _.
" Jnr Section 7031:5 by any hjhplic:mt fora permit subjects the applicant m a civil Penalty
n,rnod more,than five hundred dollars(asa). 101`�P- �1DA , ON. , `Occupancy Type
'-
C]1.asevner or the n,Pr my employees with wages as their sole cons' � t _ I•.t _�,,. �'t" tf : :'.iJl
props Y pens ion,
will do the work,and the o e:n C not immadedm offered for sale(Secy 1.an
-. 'owner ofproincy Who
Code:Tlw Conuactori License lawdoes ssuch work himself
or
103' - UFER Required Inspections - '- - -'
_
owner of hFhis ow who Malas. improve:at such,and who ams such work nded or
• or mmtrgn his own employee:.pmvhaee that sans improvements arc not intended or 10.41 - REBAR
"offerW for sale.If.however,the building- - " t is mld-walsin one ear of. — — - R BOLTS
mimen vein r 105 - ANCHOR BOLTS
mcompletion,the ownerbuildcr will have the burden of proving that he did not build or
oocfer,c,p erhfsalt.). 106 - SEWER & WATER
_ .prcrc . _ exvlu . yvdn ehxr - 202 = UNDERFLOOR PLUMBING _-_ . _...
-
.OLas owner of the nY.am exdusivel tractor thliccnsW contrecmrs to
nnswct the project(Sec.nw.Business and Professions Code:)The Convectors 2 03 - UNDERFLOOR MECHANICAL
License law does not apply....owner of propcny who builds or improves tnemon,
project,with a coawcmr(s).mansed punuant.m the 2 04- =_UNDERFLOOR' FRAME ------_-
_ .ana.wng ,s Licens L w. . ..__.
Connaaors License Law. -�--- -
❑lamexemlaooderSec: .B&PIC ror)his...a 205 - UNDERFLOOR INSULATION
Owe,<' "Bate 301 - ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 TUB & OR SHOWER
' 1
Ihereby arfim,under penalty olperjury 6ncofthefollowingdeclarations' 303 - ROUGH MECHANICAL
❑ 1 have and »'u1 maiamm it Certiro,me ofrC..,., to self-imare for Worker, 304 - ROUGH ELECTRICAL .
Compensation, as provided for by Section 3100 of the Lahor Code, for the
petrormance of the work for whim this permh is issued. 305 - FRAME
❑Ihave d� nra Worker's CPe t 'I qtr d by Section 306 - HOLDOWNS -
37rw of theLabor Code,for the vriormance Ofh-work for hich this Permitis 307 - INSULATION _ _ _
ucd MY Worker's
RTIFlCAIION OF EXEMPTION FROM reation Insurance conier and Policy
number are:
308.1.= SHEETROCK• .-
Crid I Y Policy N WORKERS' ( t v t
309• -'A'EXT-ER-IOR%LATH -
' '•_COMPENSATION INSURANCE
� • " -- . '--3'10..=„:-rINTERIOR—L'P:TH ”" � _,
(Thra'a�ctmrr6ea or&'crumple tadtnheNoutisfor one mnarendonarc 311 - SCRATCH ''.COAT
5100)or less.) �. .
enrytoi 'to rf -worknn okrrw'mmm rc 't ...._....-__313._.. .•"ROOF--NAIL".----'—' 7._...._...._._.,,,.., ._a___............._._
' ,hadmu, ply ,an,person y rrim,soajt 'been f�< b).,0,dmw�kds 501 - FINAL EliECTRICAli' ENERGY
Compe set o Law.of Calf Da¢,'
Appl cam �a•1-a .A., �o�n y � -, 502 -- --FINAL PLUMBING ENERGY ---
NOTICETOAPPLICANI:If,aftarmakingthis Lenificatcollnm c: puonyoushoula' 503 - FINAL MECHANICAL ENERGY
became subject the Worker's Compensation pmvisiom of Ne labor Code,you must
� z fonnwith'eomplywirsuch pm,iwionworthis pmitnnxamd okay -504 _= FINAL. BUILDING._ENERGY._...
Fr^ CONSTRucnON LENDING AGENCY � 505 - FINAL ELECTRICAL '
a_> vI herby offimi that mere is a emmui,tion leading agency for iha performance
of me k for w hich ir,pe t is issued(S< 3o97,Co.C) 506 GAS TEST
Lend Name
. ., —
_ _ •t._._ . .
z Lead Add x. 507 - FINAL PLUMBING
V O 1 cans(,that 1 have read this application and state that the above information is 508 - FINAL MECHANICAL
Is"I:. correct.I agree to comply with all city and county ordinances and state laws eluding 509 - FINAL GRADE
Q [� mWildingconswciion...d hereby author.m.pmsentaaves of Jiiscity to enter upon
the bo m t ed Nmpeny for n patio parismi. 510 - FINAL PLANN I NG
ry• (we) gto save: indemnify and keep hamil ss the City of Cupertino against
rn I an r. judgments,< ,t and expenses n n y m any r ccgams[aid 514 - F I NAL PUB I C WORK
C.7 Z C)ty' - q (the e m g f this"permit. 6 7
APPLICANT UNDERSTANDS AND WILT COMPLY WITH ALL NON-POINT' Issued b I � Date
SOURCE R h LATIONS. - 2-
Si
Y
sign tPpmc
ican ommr,.'.' -h Dae Re-roofs
11 1. HAZARDOUS MATERIALS DISCLOSURE - 1.
w n th- ppl cane f t m bd king occpans sr rnahml na,areo,material _Type of Roof
❑Yes pal Cade Chapter 9 12 and the Heplth and Safety
t x
ai def edb theC nnoM
Cod 5 ton 2553pe) ,: , 5( �� t r . -• � ' 1.- ' f a t : 'I r � y y
_ ser �No'•.` Lh ry �'' ' ' _ All roofs shall be_inspected prior,to-any,roofitig.material,1 einginstalled.
e'il the rpt of 'r t bidding p nor egap - t device,which If a roof is installed'without first obtaining an inspectio`i;.'Pagree'to remove
see haiE ser smnrminnnt,a,der a by the Bay Aima Air Qualty Mamgemen, ,. . ,
r ro n _ .all new materials for mspecnon. Applicant understands and will comply with
t<t. is .. 511 non pent source regulations;. :.
1 have mad be hanrdous maienale rcquhmmenis trader Chapter 6.45 of the
C.1ifnnia HealthArSafay Coda Seciom 25505.25533 and 25531.1 undamandthat
-if rhe building Jms not curten0y have a mnam.rhet it ix nr,m, mibi)iry to nmdy the
occupant of the requirements which most be and prior m issuance of a Cenifcare of
{^ `
Signature of Applicant Dale
apmon, agent: . ) . Date. All roof coverings to be Class "B" or better
crore
" =. .,:j. .. .. OFFICE