05100052 (2) CITY OF CUPERTINO (
BUILDING DIVISION PERMIT ClVT12�1.CR INk�bR �1TTr a;x,JW
V ,.
BUILDING ADDRESS: PERMIT NO,0 510 0052
7537 PROSPECT
OWNER'S NAME: PERMIT ISSUE DATE
Ighk
NOMIYAMA 10/12/2005
NE: SANITARY NO. CONTROL NO.
HITECUENGINEER: BUIIAINO PERMIT INFO
BLDG OELEC17 PLUM
ARCO O
30o LICENSED COemandmORSDECURAnON Job Descriptio
y� 1 Wreby 01.1' that 1 tan licensed under provisions eOf aChapter en(commencing
with Section 7a)0)of Division 3 of IW BuYnm um Pro(evdwm Code,arm my license Is
"'� in full ram andSZf INSTALLING CLEANOUT
LieenmGlu. t. tee. l ./3
3 F Dam Contrucr Oct).ARCHITECTS DECLAMATION
RATON CDECLAI
1 understand my plans shall W uuJ u public records V
0 c�,v Licensed Proposed aml /)�v
Og 3
OWNER-BUILDER DECLARATION y, v✓
E 0 E 1 mase .(Scc thus 11. attempt from Jle Contnmors :My c Lew for tW �[/3ytA
COO following reason.(Secdon 7031.5.Bml l and Profeuiuns Cale:Any oily m county ^^0,, $800
$� which requires•pencil m ennswct,eller,W prow.demnllxh,m repair any awcture FI
ZS^ prior to i%imumo,Rha requiras lW applicant foruch permit to rile a signed smlomem
< thnW is licensed pursuant m the provisions of ftConuacmr's Uceme Low(Charter 9 Sq.Ft.Floor Area Yal a[I'n
8 (commencing with Section 7000)of Division 3 ofthe Business and Pmfmiau Cocie)or �,
l'y that W is exempt therefrom and dm bash for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a pemdl ubjccts the APPlicanl to a civil penalty of 3 Occupancy Type
not more thm BK hundred dol Wa($SW).
❑1,uownerufthepmperty,mmyemployenwlthwagesuftkmlc=Pewdon,
will do the work,end deanumure iimaimended moQered foru4(Sec.7044,Business Required Inspections
and Professions Code:The Con amem's Llewe U.apes MI apply m an owner or 9 p
properly who bui Ida or im proves thereon,and who does s uch work himself or through his
own employees,provided that such improvements K notimended moResed fault-if. s
however,the building or Improvement Is sold within one yetr of completion,de owner-
builder will Nva the burden of proving that the did an,build Or Improve for puryoa of
ss10.
❑1,ea owner of the property,am exclusively contracting with licensed conowtoa to
construct the project(Sec.7044.Business and Profession Cade:)The Common's U- ,
ceche Law does not apply to an owner of prop ety.who Wilds or improves demon.and,
who contracts for such projects with a eom actor(O lluued Panama to use,Contractors
License Law.
❑l am smart under Sec ,B k P C for this reason
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby arrests under penalty,of perjury occur the folbwing dslantiom:
I love and will maintain aCwHicam of Coasenl lo self-hrtum fm WeakersCmepen-
atien.u provided for by Section 3700 of the L lee,Cade,fm the performance of the
work for which this Permit is Wood.
❑I haw and will maintain Worker's Compensation Insurance,as required by Section
3700 of the labor Code,for t p Porto muna of de work fm which this permit h issued.
My Worker's CampensaJ, mance hitt end Polity number are:
Cartier. T Polley N%'1K—esQ2AZV—
CERTIFI ATE PEXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thissuction need notbecompleted little permit is per onehurn m l dollars(5100)
or leu.)
I certify that in the performance of de work for which this permit is issued,I shell not
employ anypereon in soy manrerso as to bemuse subject to do WoftW Compensation
Law.of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this Carousels of Exemption,you should
become subject in the Worker's Compensation provisions of that Lorr Code,you mom
alio forthwith comply with such provisions or this permit shall be deemed remked.
z y CONSTRUCTION LENDING AGENCY
(-v IWmby alrmm that alert is.Construction lending agemy for f parr...of
(Sr'r7 the wink for which this permit h issued(Sec.3097,Or.C.)
W�Q Landers Name
z Lenders Add.
U O 1 cerdfy let I haw and this application and tele that the abuw information is
lemma.1 agmen he Comply with all city and wanly ordinances and sum laws totaling to
Q rV^ Wilding construction,and hereby authorize topreunmim of this city to color upon de
alow-mcndoned property for inspection purl mea
(We)agora to ow,indemnify end keep harmless the City of Cupertino againsl
L4] tiabllides.judgments,costs and expenses which may In soy my morc against said City
V 7 in consequence of the granting of this permll. �y
r7 APPLICANT UNDERSTANDS AND WILL OMPLY LTH ALL NOWPOINf Issued by: Date
SOURCE RJAM0PIONS,
S�
Si{rte Re-roofs
moofApplicart/ComraclorData
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or futuce building mupant mom or handle huardous material
as defined by ale Cupertino Municipal Cade.Chapter 9.13.and the Health and Safely
ode.Section 35533(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant enc equipment or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
It hrumnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
uid7
❑Yas lis
I haw mall the hasardous mu:rlats mquimannts under Chapter 6.95 of to C.iifor-
nhHnl"Safcly CO ,Scetimu35505,35533ud35534.lundermondthoufthc building
docs not currently haw a u nub Wt it Is my responsibility m amity the occupant of ale
re wee mnmW ph Poll of aRnlficaeofoccuparc mSignature of Applicant Date
owner an thorizcdegcnl Dare All roof coverings to be Class"B"or better
Community Development
10300 Torre Avenue
aClOF
Cupertino CA 95014
Telephone(408)777-3228
Fax(408)777-3333
1 .UPEkTINO
Building De artment
JOB ADDRESS: PERMIT#
753 7 P/Lo ' Aia W
OWNER'S NAME: A jo PHONE #
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:_/�422
��� aGf� oT
Signature Date
Please check applicable subcontractors and'com Tete the following 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
Owner/Contractor Signature Date
abl� 1oo �5Z
r� CITY OF CUPERTINO
' REPIPE/SEWERS/MAIN SERVICE
ICUPER,TINO PERMIT APPLICATION FORM
APN# Date:
,766 - a -e7 oGfi i� os-�
Building Address- f
S3 7 aS
Owner's Name: Phoma . _ :?SSS o3
O""
Co actor: Phone: License#:
Contact: Phone: Cupertino Business License#:
Building Permit Info:
Bldg ❑ Elect ❑ Plumb ®'
Job Description:
Residential FLor Commercial ❑
Cost of Project:
•
Qty. if '
Applicable Fee ID Fee Descri tion Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Repipe of Fixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING