01070146 (3) CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10315 VIRGINIA SWAN PL CONDITIONED AIR 01070146
OWNER'S NAME: APPLIC TION UB DATE
HOSHIZAKI MARIA I 164 B GILMAN AVE 0730 2001
PHONE: (408) 374-6311 SANITARY NO. CONTROL NO.
n azz ARCHITECTIENGWEEft: BUILDING PERMIT INFO
w BLDG ELECT PLUMB MECH
I Q W LJ L''= 1 I_I L_1
LICENSED CONTRACTOR'S DECLARATION
z 5 In 1 hereby affirm that I am licensed under previsions of Chapter 9 dommencing Job Description
°N-
° withSection/0001 of Division3ofthe Business and PrefessonsCode.and mylicense FURNACE CHANGEOUT
a m y is in full force and.Beet.
re c
as a License Cl... Lic.g
e'
0i
O Dane Contractor
a a. ARCHITECT"S DECLARATION
1 understand my plans shall be used aha public records
T
pa a p° Licensed Professional
rres, OWNER-BUILDER DECLARATION
-�' 1 hereby M.that 1 am cacmpt form the Comrsmr's License Law for the
1-Z a following reams(section 7031.5.Business and Professions Code:Any city or county. $480
ed F O which rtquircs a permit to conswet.alar,imprmx,demolish,or repay any smucts.
to -print . '
L' e.also9 p
th ' P - tlliherror i fl 'tled statement.- -
that he licensed purSa [he provisions of the Contractor v License' Low(Chapter 9 p pl r,,pp�as�a , , Valuation
(commencing with Stti 1000)of Division 3 rthe Bsine dProfessions Code) s- , z 31 51'4 EtOFT2D^ V^V',-s_, s . t�
.,,hot he is nempt!hcrefrom-end the haste fur the alleBce essir .Any storm...
-of seerion 7031.5 by any applicant fora pemut sthjoars the applic.....a civil Penalty
-
;of manoethan five hundred dollars(550)1. 30jAPNAbVtfH PLUMBIN ' o` .. '• Occupancy Type
❑I.as owner of the property,or my employees with wages as their sole compensation 303 -
willBus ne me work:and the structure C.mrintemmcen e eredI-aw'does
oaleno apply 1.an 3 04 – ROUGH EL�mRI CAkctions'' ,•
Business a wrxrkr an oth CMe:Theis n t me s License erw errs ret apply to a.
owner or property Who bands or improves thereon.and who does such work himself 505 – FINAL ELECTRICAL
or erectthrough his own employees. building
thus each improvements arc not intended or
._ ._ ..t.___. .._.._...__._
"'btrer-ed for sm, besoxhssoildethe buildingor irdenof pimooml hedid one Wild
improve
507 - FINAL PLUMBING
completion,the erect m' xic.).will have the burden of proving rho he did not WiIJ or
impmse mr parpose ar vle.). 508 - FINAL MECHANICAL \
_. lI' -- - - - - '- " --- —
❑Lasowner of the pIS- 7amadiness exclusively contracting licensed Catamarans -- - - - _ - -- ,, ;-C;'-s-.. '•I"i Is'.•
s onsm e r the t..,Phone'ISttly to a Basions and whob CtdeO Th<ves tmnor's
s,
and.,sa Law don not apply to an owner of property mwho builds ord mixua thereon.
:. .: •: . ,and,who contracts fur-such pmjcats with a cuno-nvnrgs)li.ena•J pummm to the ..___ ___._ .___._..__..... .. ..__.. _..._._ ._....-.-. ...-.__..._..._.___.....____.
i v
Contr.mh License Low o re
❑lam exempt under See.' L '„B&PCfunhis reason
0” Date
WORKER'S COMPENSATION DECLARATION
I" 1 hereby alfmr under penalty of perjury one oft he following daclmducrup
17 1 have and'will mainibin u'Certifewc of Coders! to Belt-insure for Worker's
Compensvtion, as provided for by Section 370) of the Labor Code, for the
,- - - perinnnance bf the work for which this permit is isweJ.,
FINALE
-- D 1 have aod will'mainuin Worker's Compensation Insurers ti,as required by Seniors
37W of the Labor Caus.for the Performa..of the work fur which this permit is
kZired;My Worker's Compensation Imumrice carrier and Policy;numberxre:
. -OCTJ 52001__ .-s' ......... -- _
Cairier:.,.. r. .,vr^..Policy No ',yv V.1,Psl llrs.t
ICERrI11LATION OF EKF-MITI ON FROM WORKERS k - '• ^f {COMPENSATION INSURANCE,
i,r•,' (This semm.new not at mmplaeJ d!he Permitis roe one hundred dollars _r-Cl•lls: ...l�—_.....
IS 1010)as Rest
'' V I ccs fy rhai in the performance of the I Wfo,wh ch dim peoriff is roared.I • �. -.� .• ., •._ . ..__ 1 l +I{• i r. -... .. . __ .-_
'hSll not cmplay any pecan in any manrmr so as In become subject to the Worker''
Cion,connive lows of Califtinima.Daus -
-Ap,daint
SNOTICE TO APPLICANT It,It hernnaking,his Certificate
I L emphon'You should
tecomc'dbjcn w the Workir a Canip.n.imlon proskioni of the LnMv Code,you must
Q O forthwith cmnply with such provisions or this permit shall he tm
eaed re okouL
-- --- _ ...._ .. .__.. .. ._.-... . much__. __-.- _--- -..._ .. --- --.
CONSTRUCTION LENDING AGENCY t •' r•' "' ' n
1 Worry is mor that flues,is a or.,fruition IcrWinB aSe.Y for the performance'T4
of the work for which this p2mrit is issued lSee 3WL Cis. Js..
0. Q '1c9dcrs Name" ..-...' '•-'_. u ...., .I t
Lend
V Q 1 certify that I have reade'. ppl t J Start that bove information is
LL'F. eco m 1 agree ro comply nM 11 city as usunty polinnot am state It orating
Q l.7
to buildingc sr' t ttd hereby mahmiz,representatives.1 this cuyr.rater ups.
�,. the above mentioned pi pen f peer purposes.
E.r-d Us 1 8 t indemnify andkeep h srheCtY ofCupertino against
-rn Iiabdrues,judgments.costs and expense. which may in any 'ay ace against said
V Z City in'nmsequende of the grantingof,h if permit'
APPLICANT UNDERSTANDS AND WI LL COMPLY WITH'ALL NON:POIM1T.n' Isslledb Dale
• SOURCE'REGUIIA'f10N5.' ('I':'. y
Sipgature or ApplicaMCobtracton- �" " " ' ;Date:' " Re-roofs
HAZARDOUS
MATERIALS DISCLOSURE
` SJditheyront
lkanCruturewaoccupant dingoapNneathandleehiscarabuamarerial .Type of.Roof
Its
dcfred by the Cupertino Municipal Code Clu pier 9.12.and the Hemet mrd Surety
cod s to u53'_bm r !. 1; s ♦. .p:`..,, .;. t.
0Y°' P"° All_roofs.shall be inspected.prior.to.any.rbofing.material being,inslalled..-
WII the ppr t or future Wilding occuport useeq n t or devices etch If a roof is installedrwithout first obtaining an'inspectiom 7'agree'to remove —
m t h 'cornus n r co t t rano tai Jct n'd nY the Bey Arca Au Ouahry Alunapemenr
oi.m.e. ; � � all new materials for inspection. Applicant understands and will comply with -
r.oyea . ',.-oNp •.,�., all-non-point source regulations.
I have read the hhr5rdous:mmcrials mquiremints,under Chapter 6.95 of the
Califomis Hafth&Safety Coi Sections 25505.25533 and 25534:I understand that
if the building docs not currently have atewm,that it is my¢iponaibilityto notifythe -- --- --- - - -- -- - - - -
pccupant of the rcquircmenta which must Fe and prior m issuan.e bl a Cenifcate of
.. pan Y
Occu b•IdV!
�. r•' _ • - - _' _ "' ^ • .._ - - Signature of Applicant, . ._, . .-_ .-_ -__- . - - Date
All roof coverings to be Class"B"or'better'
Owner or authorized agent l ,. P"' Dore g
OFFICE -.. .. ... .. . _ .... .. .. _ . _ .