03110107 (2) CITY OF CUPERTINOr _ •r ^'f, la
BUILDING DIVISION PERMIT CONTRAC"TOR INFORMATION: .
sn�r.LF'•iVfE
BfJILDING ADDRESS: D. C. TAYLOR COMPANY PERMITNOO 3110107
22791 STONEBRIDGE ST
OWNER'S NAME: PERMITISSURDATB
IghQSHIYUKI FUNAKI 140 MASON 11/20/2003
NE: SANITARY NO. CONTROL NO.
(925) 603-1100
ARCHITECTXNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
!Oo LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm that 1 am Ilcenxd under previsions of Chapter 9(commencing Job DOSCrIpIIOn
with Section 7").f Division 3 of dm Business and Professions C.&..ad my license is
in full face and er .o t /6 6 BATH LIGHT & FAN
License s Lic.N
Data • Contractor Ar
p ARCHITECT
I understand my plans shall he.-A4=7
>�U
e Liccnud Pnafcssinnel
OWNER-BUILDER DECLARATION
10
af 1 hereby affirm that 1 am exempt from the Contractor's Licenu Law for the
C20 following reason.(Section 7031.5,Business and Profusions Code:Any city nr county
which requires a permit to construct.Alma improve,demelish,or repair any structure ssso
�2Y prior to its issuance,also requires the applicant for such permit to rite a signed Nuancal
m<
I hat he islimosed pursuant to the provisions aftheConlatcher's Limax Law(Chadeng Sq. Ft. Floor Area Valuation
el-$ (commencing with Section 7")olDivision 5 ofthe Business and Professions Cavi or
.- Nat he is exempt therefrom and dm basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil Penalty ofer Occupancy Type
not more Nan five hundred dost...($50(1). PanC Y YP
I,as owner of the property,or my cmploycu with wages ss their sale compenudon,
will do Ne work,and the suuame is not intended or offered fossale(SAc.7044,Business
and Pmrcssiona Code:The Cmdranors Lim.Law does not appy m an owner of Required Inspections
progeny who builds or improves thereon,and who does such work himself orthreugh his
own employees,provided that such imprevedems are not intended or offered for sale.If.
however,he building or improvement is said within one year of completion.Ne owner
builder will have the burden of proving Nn ne did not build w improve for purpose of
sale.).
❑1,as owner of the properly,am exclusively contracting wit licensed contractors to
construct the project(See.7D44,Business and Professions Code)The Contractor's Li.
cense Law does not apply to an owner or properly who Wilds or improves thammn,and,
whofor such projects with aconvacmrtq licensed pursuant re the CContractor'sLicen.Law.Law.
I am exempt under Sec. ,B As P C for this reason
Owner Dau }
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penally of perjury one of the following decimations: V O�
I ban and will maintain a Cenifc.te ofConamt u self-Insure for Worker's Compcn.
satlon,ss provided for by Section 3700 of are labor Code,for the performance of the
work for which this Permit is issued, -
I have and will maintain Wurkces Compenation❑nuance,as required by Seefinn
700 of he labor Code,for the performance or Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am: 44�
Carrier. .S• Y- 4 Policy No.:4.)4"0.3'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuction med nu M comocud if thepermit b foroachundred dollars(5100)
or lees)
I certify Nu in the performance or the work for which this permit u issued,I shall not
employ any person in any manner an as a Mcome subject to the Workers'Cmmpcnadon
Laws of Celifmmic Dau
Applicant
NOTICE TO APPLICANT:If,arm,making his Ccnificam of EmmPtom.you should -
become subject to the Worker's Compensation provisions of viae Labor Code,you maw
�z urthwithmnn,I,with such uvisiomaordid,Permit sh.11hedcededrevoked.
Z O CONSTRUCTION LENDING AGENCY
1 hereby a(Iirm can time its consmuctinn lending agency,tar the performance of
5 the work for which this permit is issued(Sec.3097.Civ.C.)
S.1 Q lender's Name
lender's Address
�z
U Q I mnify bat I have read this eprpfntimn and sate that be shove information is -
ly P Carnot.1 agree m cmmply with all city and county artinances and sae laws relating to
pU building Coronation.end hereby Andiron maxacautives of his city to enter upon the
D.l above-mentioned property for Inspection purposes.
g), (We)agree re save,indemnify and keep handless the City of Cupertino against
.wcA liabilities,judgments,casts and expenses which may in any way new against said City
U z in consequence of the graming of this permit.
" APPLICANT U RSTAND A LL COh LY WITH ALL N N-POINT Issued by; Dat
SOURC RE ATIOIN • /p
///2a/D7 Re-roofs
Signaturemf AppliceH ZARDOUS MATERIALS DISCLOSURE Dau Type of Roof
Will the applicant or future building occupant srert or handle harmdous mmunal
as defined by the Cupertino Mu 'cipal Code,Chapter 9.12,and the Health and Safety
Idc.Section 35531(x)? All roofs shall be inspected prior to any roofing material being installed.
Yes Nu
Will the applicant or comm banding occupant m =gaipm=ret or d=ei=ces which If a roof is installed without first obtaining an inspection,I agree to remove
It Khmadous air conamina recd by the Bay Area Air Quality Management all new materials for inspection.
viel?
Q Ycs ❑NuIth wmWOchanNiwimawrialsmquimmenuundcrChapnr6.95oft Califor-
Health@SafetyCo .Smdom25515.25533wd25534.1understandNuuiyr�d7c1 bbuuildiing
es notcurcmlyhIt u toll u m eappM ottnrah
uimmcnts whic hemet ' r ceohC ificau f Occu Signature of Applicant Date
Aland agent Date All roof coverings to be Class"B"or better
11/19/2003 23: 21 5105303202 LEGALITIES INK PAGE 03
;(CCS CITY OF CUPERTINO
PE
FtTINO PERMIT APPLICATION FORINT 6 3 � � � � ` 7
APN # 6 Date:
BuildingAddress:
Z 2 7
Owner's Name: D � �M � Phone -Z ,7 O
Contractor: ��t[J rJ License#:
� . C . � � • U sips �
Contact: _ Phone #:
Applicant/Contraeter• Fax #:
Building Permit Info:
Bldg Elect Plumb Mech
Job Descri tion:
Residential � .� 2,✓ Commercial:
Sq. oor Area: S/Sq.Ft.:
Architect/Engineer: Valuation:
SSo 6v
of Construction: Occupancy Group:
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER Other A liances I MECHANICAL
BBLDGFEE Bldg Permits . foot BUILDING
BBOILERI Boiler<= 100,000 Btu MECHANICAL
BBOILERZ Boiler> 160K to 500K Btu MECHANICAL
BBOILER3 Boiler> 500K to 1M Btu MECHANICAL
BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL
BBOILER5 Boiler> 1.75M Btu MECHANICAL
BCONSTAX Construction Tax I BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
JBCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH I Hotel and Motel , BUILDING
BCONSTAXR Constax —Resi/Mobile BUILDING
BELEC1000 Elec 600V <= 1000A ELECTRICAL
BELEC1001 Elec 600V > 1000A ELECTRICAL
BELEC200 Elec Svcs 600V <= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
BMITIGATC Comm. Housing Mit. Fee BUILDING
I of3 ��
11/19/2003 23: 21 5105383282 LEGALITIES INK PAGE 06
' 2J�Z
CITY OF CUPERTINO
u.PErZTirvo PERMIT APPLICATION FORM
QuantityFee ID Fee Description Fee Group —�
BREMPOWER Power Device/Apparatus ELECTRICAL
BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL
BREMRELOCARelocation of Hood MECHANICAL
BREMREPALT Repair/Alter Heating MECHANICAL
BREMRESAPP Remodel Res Appliance ELECTRICAL
BREMSIGNAD 1,Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Remodel Signs, Marquee ELECTRICAL
BREMTHEATR Theatrical Lighting Fix ELECTRICAL
BREMVENFAN Vent Fan Single Duct MECHANICAL
BREMVENSYS Ventilation Systems MECHANICAL
BSCBLVD Seb Specific Plan BUILDING
BSEISMICOM Seismic Commercial BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSF&2FAM Single & 2 Family BUILDING
BSFNA Single Family New Add BUILDING
BSPECIAL I Special Inspection BUILDING
BSWIM Swimming Pool BUILDING
BTEMP Temporary Power ELECTRICAL
BTEMPPERM Tempo Bldg Permit BUILDING
BTEMPSVCS Temp Dist Svcs ELECTRICAL
BUSLIC Business License BUILDING
ELECTRIC Electrical sq foot ELECTRICAL
L—r
_ EPERMITFEE Elec Permit Issuance ELECTRICAL
MPERMFEE Mechanicals . foot MECHANICAL
MPERMITFEE Mech Permit Issuance MECHANICAL
PPERMITFEE Plumbing Permit Issue PLUMBING
PPLBG Plumbing Fee sq foot PLUMBING
ZADDCHG Address Chane BUILDING
1 812E M l2 t x r I- ,Q
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