07030343 CITY OF CUPERTINO
BUILDING DIVISION PERMIT :INFOR , ATI01
BUILDING ADDRESS: - PERMIT NO.
OWN A
'ONKIKUCHI NED I AND MARY E SEF DON CT SAWM-2 U-01 CONTROL NO.
ARCHITECT/ENGINEER: (519) 376 4816 BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
>p LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing p
a with Section 70(X))of Division 3 of the Business and Professions Code,and my license is
in full force 3z License Classdeff Lic,0 7t1'8- J REPLACE WATER HEATER
p Date Contractor
IN RCHITECTSDECLAR TION tV
a I understand my plans shall be used as public records
QU
ti Licensed Professional
]
rOWNER-BUILDER DECLARATION
aj
_ I 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
y prior to its issuance,also requires the applicant forsuch permit to file a signed statement
=o that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 q.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Businessand Professions Code)or
3 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 araC APN Number OCCu
not more than five hundred dollars($500) p y Type
❑I,as owner of the property,or my employees with wages as their sole compensation, 3562404L . 00
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Contractor's License Law docs not apply to an owner of Required Inspections
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.).
❑I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's 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 Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
have and will maintain a Certificate of Consent to self-insure for Worker's Compen-
.,on,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑1 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 Worker's Compensation insurance carrier and Policy number are:
Cartier. PolicyNo.:C-06a1fl�>'—fr _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars($100)
or less.)
I cerdiv 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.
CONSTRUCTION LENDING AGENCY
r-i I hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
M Lendces Name
z Lender's Address
Q 1 certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating to
Vbuilding construction,and hereby authorise representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
G]. (We)agree to save,indemnify and keep harmless the City of Cupertino against
rn liabilities,judgments,costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit. �+
►-r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date 2—Y 7
SOUR EGULATIONS.
-) �
Re-roofs
Signatu�of Applicant/Contr cior Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
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)?
❑Yes � /o All roofs shl.11 be inspected prior to any roofing material being installed.
�N
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
.uict?
❑Yes u
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 currently have a tenant,that it is my responsibility to notify the occupant of the
requirements which must be met prior to issuance of a Certificate of Occupancy. Signature of Applicant Date
A� 313,3/ y� All roof coverings to be Class"B"or better
Owner or authorized agent —sate
CITY OF CUPERTINO
WATER HEATER
00f
CUPEkTiNO PERMIT APPLICATION FORM
APN# —3 0 Date:
Building Address: 1
2:.1`-1 O 5 Renno, c-i- d� .
Owner's Name: Phone#:
yn1 CW - 40`K f�J -71 4774
Contractor: P r License#:
Ina, t
Contact on Cupertino Busines License#:
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Building Permit o: —
Bldg ❑ Elect Plumb Mech
Job Description:
J
Residential Commercial ❑
Cost of Project:
I
Stra�P_ped___EP, On platform Bonded
New Location ❑ Replacement
Qty.Y- if
Applicable Fee ID Fee Description Fee Group
BPWI"EATER Water Heater/Vent BUILDING
PP _Plumbing Permit Issuance PLUMBING
BENE GY Energy BUILDING
BUS C Business License BUILDING
i
I
i
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
CfTY OF
CUPtNO Fax(408)777-3333
E�T
Building Department
JOB ADDRESS: PERMIT#
211 b5 R �1oti 4?c
OWNER'S NAME: PHONE #
GENERAL CONTRACTOR FAX #
I am not using any subcontractor
Signature Date
Please check applicable subcontra urs and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date