02120003 (2) CITY OF CUPERTINO -
BUILDING DIVISION PERMIT CONTRACTOR'INFORMATION: t
Bu3L11001161s.WILLOWBR00K WY TOM ' S PLUMBING PERMITN102120003
OwWAKAGAWA TAD T AND BERNICE 12246 SARATOGA SUNNYVALIBPLWATT4gYYV.YV 2002
IONIi: (408) 867-6010 SANITARY NO. / / CONTROL NO.
ARCHITIiCrIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
MDp LICENSED CONTRACTORS DECLARATION�rqO O O O
F I hereby affirm that 1 am Iicen¢d under provisions of Chapter 9(commencing
with Section mXm3
XBDmi,ionnfan
the Bt.�:R�Rxan0 Prnreasion.,Codc, u my Ii is WATER HEATER I �La'1`�t�
/I NT
in minO effect. ✓� ��`��'sss���
WK= Lmcnmsc¢l�ag�ry`'f c— �8����®
Fp f effect.
DIHCL
Al IOU
Iundcmand my pl nsshallM Jas pu Ac ecorrdx ` DEC 0 4 2002
OaU
wLLLLG Licensed 11 lecsluna
F--p OWNIiR-BUILDER DECLARATION
rc y'4 a P I herchy allirm Thal I am exempt from the Commetiox Licenm Law for the BUILDING
$575
w p O following reason.(Section 7031.5.Business and Professions Cock:Any city or county v�/
o'400 which rc,mies a permit or consvun,alte,imp,ovc,demolish,or repair,any st,u,l..
ca—vi poor It)its i.auanec,also rcyvirevhe applicant for such Permit o Glc a signed statement
Mizo thalheixliecnsedpursuanitolheprovisionsolOcComracooil-ocmxLaw(Ch,tm,9 __-FAM2t*lSAr0+0 Valuation
M (commencing with Section70)(x0 of DoNion3ofthc Business and Profession Cole)m
a 3$ shat he is exempt d cefmm fid the basis fnr the alleged exemption.Any vimatlnn of
Section 7031.5 by any applicant far a permit subjects the applicant to a civil penahy of NYN ecupancy Type
nut tone than five hundred dollars(1500). 506 - GAS TEST
❑I.as owner of the properly.or my employees with wage as their role compensation.
will Jo the work,and the structure is nm intended or offered for sale(Sec.9000,Business
and Professions Code:Thc Conlnclors License Law does not apply to an owner of egmre nspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements am not intended or offered for sale.If.
however.Ne building or improvement is sold within one year of completion,the owner
builder will have the burden of proving Nm he did not build or improve for purfnsc of
side 1.
I,as owner of Ne property,am excleively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Cudeq The Contractor's Li-
cense Law does not apply to an owner of property who builds or improve thereon,and
who tontracu for such projects with a contranons)licensed pursuant to the Contractors
License Lew.
❑1 am eacmpt under Sec. .B At P C for this remain
Owncr Dam
WORKER'S COMPENSATION DECLARATION
I hereby aBimt under Penalty of perjury one of the following declarations:
I neve and will maintains Cion 3700 of C c Labor
Code.[or for Worker's Compem
section,u provided for by Section 3'/1X1 of the Lehr COdc,[or the perinrmance or the
work for which this penis is Laved.
1 have and will maintain Worker's Compensation Insurance,as oxidied by Section
3700m the labor Ede,for the primm ance of the work lie which this(moil is issued,
My Work�se,r's C�omle�nselion lnsumnce extra, and Policy n her am:
Carr'cr. GO,Y/9.a PolicyN !I
CERTIFICATE 'EXEMPTION I' ORKERS'
COMPENSATION INSURANCE
(Thi,Semon need not M cnmplced if the Permit is for one hundred dollars MM)
Icsa.)
1 certify that in the Performance of the work for whish this Permit is issued.I shall not
employ any cram in any manncrm as to hccome.utijecuo the Workers'Compensation
Laws of California,Dale
Applicant
NOTICE TO APPLICANT:If,after making this Ce ilinte of Exemption,you should
firearm subject to the Worker's Compc nsminn provisions of the Wbnr Code,you must
O ,Z, forthwith comply with,nch provisions or this pembil shall be deemed revoked.
zO CONSTRUCTION LENDING AGENCY
EN. Ihereby affirm Nal there is a Construction lending agency[(it he Performance of
7 the work for which this permit Is issued(Sec.397,Ctv,C.)
R1 Lenders Name
Lender's Add..
U O 1 cenify Nal l have read this application and suite Ih:n the above information is
U. F' correct 1 agree vs comply with all city and county ordinances and sure laws echoing to
C) U building construction,and hereby aubmaim representatives of this city to come mo the
raise mentioned property for inspection purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against
rh liabilities.judgments.costs and expenses which may in any way accmc against said City
U z in consequence of the granting of this permit
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU ATIONS.
LRe-roofs
m of plifanVContfacon Do,,
IIAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicantu, utum building Occupant store or handle hvzrdou,material
as JcOncJctio by the Cupcnino Municipal Corte,Chaper 9.12.and the Health and Safety
Code.Sezss3xa)'?oyes > All roofs shall be inspected prior to any roofing material being installed.
<IfNn
Will the applicant fir future buildingOccupanl use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit hnardouv aircnnmminnlsy.'defined by the Bay Arca Air Quality Management all new materials for inspection.
District'? ,`� pl
❑Yes
1 have real the hurardom mutcrials"mmments under Chapter b 95 of the Cali foo-
or.Hemtb k Safety Cask.Sci 255)5,25533 and 255.W.1 understood marf the building
docs not currently have a tenant,that it is my momasibility m notify @c Occupant of the
req ramentswhich mustMmet nnnnfaCerlmn fir a ancy. Signature of Applicant Date
a Z J L All roof coverings to be Class "B" or better
cr firs rivcJagcnt Dmc