07080178 CI'T'Y OF CUPERTINO 777 7,
BUILDING DIVISION PERMIT � JEZ
PERMIT NO.
BUILDING ADDRESS:
910 FT BAKER DR J&S QUALITY CONSTRUCTION 07080178
OWNER'S NAME: �- PERMIT ISSUE DATE
NAOKI SHIMAZAKI 2849 TULARE AVE
SANITARY NO. CONTROL NO.
NE:
(415) 699-9046
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
0 0
Z LICENSED CONTRACTOR'S DECLARATION
o Job Description
U1 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
z w with Section 7000)of Division 3 of the Business and Professions Code,and my license is ADD ELECTRICAL SUB PANEL UNDER 200 AMP S
in full force and effect.
? License CILic•it
F p Date -Contractor •
f ARCHITECTS DEC N
I aa
< I understand my plans shall he used as public recoils
Tu
u,F Licensed Professional
OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
which requires a permit to construct.alter,improve,demolish,or repair any structure
Z y prior to its issuance,also requires the applicant for such permit to file a signed statement Ft. Floor Area Valuation
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq
_ (commencing with Section 7000)of Division 3 of the Business and Professinns Cade)or $5000
IRE that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of ��}{D�{*,T Number Occupancy Type
not more than five hundred dollars(S500). 35611030 . V V
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044.Business Required Inspections
and Professions Code:The Contractor's License Law does not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
0 I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves thereon,and.
who contracts for such projects with a contractor(s)licensed pursuant to the contracts
License Law.
❑I am exempt under Sea B&P C for this mason
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations
I have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is Issued
My Wor is Compensation Insurance carrier and Policy number are:
Carrie Policy No.: e
CERTIFICATE OF EXEMPTION FROM WORK S'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I certify that in the performance of the work for which this permit is issued.I shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
z" CONSTRUCTION LENDING AGENCY
F+ I hereby affirm that there is a construction lending agency for the performance of
tYi> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
2 Lender's Address
U 0 1 certify that I have read this application and state that the above information is
LI~" coconstruction,ct.I agree to comply with all city and county ordinances and state laws relating to
rJ ing construction,and hereby authorize representatives of this city to enter upon the
U build
U above-mentioned property for inspection purposes. /117
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilities,judgments,costs and expenses which may in any way accrue against said City
U Z in consequence of the granting of this permit. Dated--J
t " APPLICANT UNDERSTANDS ND L COMPLY WITH ALL NO Issued b,i:
SOURCE REGU of: 441aerk�' 41—Z
° Re-roofs
Signature pplicanV to ate Type of Zoof
HAZARDO MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof:;shall be inspected prior to any roofing material being installed.
E]Yes /IVa If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
.,mit hazardous air contaminants as defined by the Bay Area Air Quality Management all new 1 naterials for inspection.
District?
O Yes
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs not curentiy have a tenant,that it' my responsibility to notify the occupant of the
rcyuircmc faCcnificatcof ry Signatur�of Applicant Date
Ir— ` v All roof coverings to be Class"B"or better
Own or authonze agent are
CITY OF CUPERTINO
3 ITEMS OF 3 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Bl.c: Lot:
APN 35511030 . 00
DATE ISSUED. . . . . . . : 08 /20/2007
RECEIPT #. . . . . . . . . BS)00002427
REFERENCE ID # . . . : 07)80178
SITE ADDRESS . . . . . : 91) FT BAKER DR
SUBDIVISION . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER NA,DKI SHIMAZAKI
ADDRESS . . . . . . . . . . : 91) FORT BAKER DR
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4010
RECEIVED FROM . . . . : GU2ISGU SENGOKU
CONTRACTOR . . . . . . . : JO3E MURCIA LIC # 29257
COMPANY J&3 QUALITY CONSTRUCTION INC.
ADDRESS 2819 TULARE AVE
CITY/STATE/ZIP . . . : RI�HMOND, CA 94804
TELEPHONE (415) 699-9046
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BELEC200 METERS 1 .00 29.43 0 .00 29.43 0 . 00
BSEISMICRE VALUATION 5, 000 .00 0.50 0 .00 0 .50 0. 00
EPERMITFEE FLAT RATE 1.00 38.37 0 .00 38 .37 0. 00
---------- ---------- ---------- ----------
TOTAL PERMIT 68. 30 0 .00 68 .30 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CREDIT CARD 68.30 VISA
---------------
TOTAL RECEIPT 68 .30
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
103 UFER 304 ROUGH ELECTRICAL
505 FINAL ELECTRICAL
-..- ......
CITY OF C'UPERTINO
CU� �.F PERMIT APPLICATION FORM
PN# 3,5'&
� Date:1/ C�0 � $ � o
Building Address: Mailing Address (if different from building address):
to 4g
Owner's Name: Phone#:
Contractor: License #:
Contact: ' Phon 10Cupertino Business License#:
Fax: _ O�
Building ermit Info: � �,(� � Vh4. L kr of zaiEt..
Bldg ❑ Elect Plumb ❑ Mech ❑
Job Descriptio
Residential Commercial ❑
Sq.Ft. Floor Area: Sq.Ft.:
Cost of Project: Occupancy Grou
spa,— CL--�
Type of Construction: Please check this box if the project is a
second-story addition: El
-oject Size: Standard E"'- Large ❑ Ma or ❑
Quantity Fee ID Fee Description Fee Group
BAPPLOTHER ether Appliances MECHANICAL
BBOILER1 Boiler<= 100,000 Btu MECHANICAL
BBOILER2 Boiler> 100K 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 BUILDING
BCONSTAX Ind/Off/Comm/Quasi BUILDING
BCONSTAXBQ Con. Tax for BQ Zone BUILDING
BCONSTAXH Hotel and Motel BUILDING
BCONSTAXR Co:lstax—Resi/Mobile BUILDING
BELEC 1000 El-1c 600V <= l OOOA ELECTRICAL
BELEC1001 Elec 600V> 1000A ELECTRICAL
BELEC200 Elec Svcs 600V<= 200A ELECTRICAL
BENERGY Energy BUILDING
BENERGYADD Energy Add Multi BUILDING
BINVESTIGA Investigation fee BUILDING
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