05030001 (2) CITY OF CUPERTINO «'tea-may +,�' '� K•a `� ^
BUILDING DIVISION PERMITc,4) ACTOYt TNk' )IYMATI(3N
BUILDING ADDRESS: YASURAOKA TERUO AND NORIKO """05030001
21113 RED FIR CT
OWNER'S NAME: PERMIT ISSUE DAM
YASURAOKA TERUO AND NORIKO
ONE: SANITARY NO. CONTROL NO.
CHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG CLECT PLUMB MECH
t o
30p
LICENSED CONIRACIOR'SDECLARATION JobDescription
Z 1 Mreby Stolon that I am Ikxesed under prevision,of Chapter 9(commencing
x with Salion 7M)of Division 3 of the Buunessand Profcaume Code,indmy license is
^< infulliChassdeRecs BATHROOM REMODEL
Llecnse Clw Ls.a
Dem Contractor
?i A "IECTS DECLARATION
.5
'3j 1 understood nJ my Pia1W1 be usul u public records
S�q Licensed Professional
OWNEtime
DECLARATION
q I herebyRirm reby athat I sinm exempt
from tiro Conuacla od License law for thic
my
0 o which m mown.(Section 7071.5,Business roti Ne,dcCoua Code:Any city or county r
$lei which Its imu•Perm.to quires the
e elect,improve,demolish,or repair Soy Souclure 1 �'
lead msliesed pursuant
requires prevision of for wchpermr mOlcaslPnCJ ilatemcnl
< lnatberencemedpunwmmthe pm�,ioneorthe conlrncmrsueenra<_r, pmr9 Sq.'F 1716&Area Valuation
z❑9 (commencing with Senion7000)of Division 3 of the Butim'vwd RaRssine Cnde)or � . 1 f'�.,
3.. that he is eampt therefrom and the Were for the alleged exempdom Any violation of I '1 _
Section 7031.5 by Lary applicant for a permit Subjects the applicant m..I'll
penalty ofe10'O 1 --7 r Occupancy Type
not msec then it"hundred dollars(S500).
❑I,u ownerufthe property,ormyemploye a with wagese theirmlecompensadon,
will do the wok.and Ne,munure re not Intended oraaered for.1..1044,Intoes is s— ' t
wee Rareedae cave:Toe canuacmr,ueerase law Lae,wt wpty m an owner ear Req fired In`spec[l.ons ,I .
propertywwbuilds orimpmveathrown.and whodoessucb wok himselforthmugh his fJ Z17--i
� /V/'
ownemployeea,provided that each Improvements are not Intended Conflicted forsale.If. i
however,the wilding or improvement Is Sold within one year of Completion,the owncr. I
wilder Son how she Wutden of proving that he did oat Mid or Winnow for puma:of .j
emu.
❑1,u owner of the propenY•am exclusively contracting with licerued contraciers m
constrict Bre project(Sec.7014 6winess and Pm ON Cade:)The Contranars Lb
cc=law dose not apply m w owner of p who wild,or improves thereon,rod.
whocontnctsfouuceprojecu with. mNO licensed pursuant in the Contractors
License Law.
am Caere Iundefsee. � Bk PCfmthismafon
Owner
ORKERS� MPFNs�O�RATION
1 hemby.aim uMe pe.Ily of penury arc of die following declanuons:
haveaM will mained aCWfi-WofComntmelf.iuumforWakersCompen-
m,u provided fm by Section 3700 of tbe labor Code.for the perfamance of the
for which this permit is issued.
❑1 have and will maintain Workers Compensation Insurwm,u required by Section
3700 of tie tabu Code,for thepufommm of the wart fm which thispemii a iss,
My Workers Compensation Insurance tinier and Policy number sin:
Cartier, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(This section reed not be completed if the permit N foronc hundred dollars($IW)
m less)
1 certify that in the performance of the work for which this pemit he issued.I shall not
employ any Perron in any mannerw e to become subject to the Workm'Compemation
Laws of Califa ate
Applicant / —
NOTICE APPLnI If.gWrookint,this taut of Eacmplion.you thould
become subject in the Worse.Compensation provisions of the labor Code,you muse
,J O foMwith Comply with such provisions w this permit"I be deemed revoked.
'Z y CONSTRUCTION LENDING AGENCY
[-+ Thereby M.
that drum..Construction lending agency for the parramarox of
C> the wart for which tan Perna is issued(Sac Som,Cie C.)
tiGj senders Nam:
7 z Lcudees Address
U O 1 Certify that 1 hive read this application Led mm the the shove information is
it,;"! correct 1 agree in comply with all city and county ordinances and sum law,relNng m
C)lS.^J wilding convection,and hereby a duras,representatives of N.city to enter upon the
W ab w.uncro mted property for impenion purposes
G (We)agree to eve,indemnify and kcop harmhus the City of Cupertino against
h Ilabllldes.ludgmenWcosu wdexpenae,which may in Soy way accnie againsteld City
U,vZ in coivcguenee of the grooming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. _,
;/���� e//' � 25 Re-roofs
Si mofA dConuacmr
HAZARICKIIIIS MATERIALS DISCLOSURE Type of Roof
WIII the,applicant or future wilding occupant store or handle humdoua material
So defined by ted Cupertino Municipal Code.Chapter 9.11,and the Health and Safety
Code.Sec[D Y..Yuallo• ` All roofs shall be inspected prior to any roofing material being installed.
_ Will ted applicant or future wilding occupant use,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
h haefdous air comemi u u defined by the Bay Area Air Quality Management all new materials for inspection.
vict7
El yet u
Its mal the he.rdmsmsmrrere mgoimmenu underChapmr6.95off Califor-
niaHealthh SafclyCade,Secdoe25505,25733 wd25534,1 undemmnd thm]f thC wilding
does not currently haw a mnwL that It 6 my responsibility m notify dm Ccculwnt of the
rcyulmmenuwltichmuat Wcromprior deuce ear,Cenine,m ear Occapanry. Signature of Applicant Date
Son r of Lal do sit 3 Dam All roof coverings to be Class"B"or better