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06100103 77 77 CITY OF CUPERTINO { BUILDING DIVISION PERMIT � *!��R_ BUILDING ADDRESS: PERMIT NO.06100103 21592 COLUMBUS AVE, PERMIT ISSUE DATE OWNER'S NAME: NAKANISHI SANITARY NO. CONTROL NO. NE: BUILDING PERMIT INFO ARCHITECT/ENGINEER: BLDG ELECT PLUMB MECH 0 0 0 O p LICENSED CONTRACTOR'S DECLARATION Job Description 1 — I hereby affirm that I am licensed under provisions of Chapter 9(commencing U U with Section 7000)of Division 3 of Ute Business and Professions Code,and my license is !mawin full force and C: .5< �4 Z I�;Z TEAR OFF SNAKES, INSTALL OSB, 30LB FELT LaenscClass L� Date # INSTALL PRESIDENTIAL TL AND TRIM 31 SQ. F Contractor ARCHITECTS DECLARATION aI understand my plans shall be used as public records t�U •a U.y Licensed Professional y OWNER-BUILDER DECLARATION r I hereby affirm that I am exempt from the Contractor's License Law for the 3 p O 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 t z y prior to its issuancalso requires Urs applicant for such permit to file a signed statement 9 Valua0Q,12 9 0 0 _ that he is licensed pursuant to the provisions of the Contractor's License Law(Cha rer 9 S Ft.Floor Area F_ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or 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 APN Number Occupancy Type not mere than eve hundred dollars MW). 35618054 . 00 ❑I,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 9 P 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. ❑1 am exempt under Sec. B&P C for this reason OwnerDate WORKER'S COMPENSATION DECLARATION I 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 Worker's Cgyntpe aeon Innnsssyif����eee carrier and Policy number+be�am: Carrier. 1 ` ioolicy No.:�y`r "`� CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one hundred dollars($100) or less.) 1 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 Z forthwith comply with such provisions or this permit shall be deemed revoked. z O CONSTRUCTION LENDING AGENCY Fr I hereby affirm that there is a construction lending agency for the performance of p(.7 the work for which this permit is issued(See.3097,Civ.C.) W ALender's Name az L..cndees Address U 0 I certify that I have read this application and state that the above information is vL r-" correct.I agree to comply with all city and county ordinances and state laws relating to C U building construction,and hereby authorize representatives of this city to enter upon the W above-mentioned property for inspection purposes. f3. (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. Date ►" APPL6�Fcl_ ANDS A WILL MPLY WITH ALL NON-POINT Issued by: i O SOURS. Re-roofs Signature of Applicant/Contractor ate 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)? All roofs shall be inspected prior to any roofing material being installed. [:]Yeste1� 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 emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection. District? ❑Yes �16 I have read the hazardous materials requirements under Chapter 6.95 of the Califor- nia Health&Safcty Codc,Sections 25505.25533 and 25534.1 understand that if the building docs no curently ha a Fantt is my ponsihility to notify the occupant of the require ens which tp' iss ofoecn ancy. I - Signature o Applicant Date � Dare All roof coverings to be Class"B"or better Owner or authorized agent Xw �, Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone(408) 777-3228 CITY OF Fax(408)777-3333 --UPEkTINO Building Department JOB ADDRESS: PERMIT # 'Z j 5- =Z— 06'r0 0 / 0 OWNER'S NAME: 1-41Z-, PHONE # GENERAL CONTRACTOR: \ v Q-,q+` C-1 FAX # I am not using any subcontractors: L�:(c Signature Date Please check applicable subcontractors 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 ri zo Owner/Contractor Signature Date CITY OF CUPERTINO 3m 1 of 1 PERMIT RECEIPT OPERATOR: kiersaw COPY # 3 Sec : Twp: Rng: Sub: Blk: Lot : APN . . . . . . . . : 35618054 . 00 DATE ISSUED. . . . . . . : 10/13/2006 RECEIPT # . . . . . . . . . : 36429 REFERENCE ID $# . . . : 06100103 SITE ADDRESS . . . . . : 21592 COLUMBUS AVE SUBDIVISION . . . . . . CITY . . . . . . . . . . . . . . CUPERTINO IMPACT AREA . . . . . . OWNER . . . . . . . . . . . . . NAKANISHI ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , RECEIVED FROM . . . . : ERNEST BUENTIEMPO CONTRACTOR . . . . . . . : LIC # COMPANY . . . . . . . . . . ADDRESS . . . . . . . . . . CITY/STATE/ZIP . . . : , TELEPHONE . . . . . . . . . FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL - - - - - --- - - --- ----- - ---- - ------- -- ---- ------ --------- - ---------- ---------- BPERMFEE VALUATION 13 , 000 . 00 201 . 96 0 . 00 201 . 96 0 . 00 BSEISMICRE VALUATION 13 , 000 . 00 1 . 30 0 . 00 1 . 30 0 . 00 ---------- ---------- ---------- ---------- TOTAL PERMIT 203 . 26 0 . 00 203 . 26 0 . 00 METHOD OF PAYMENT AMOUNT NUMBER - - - - ---- - ---- ---- ------------ ------------------ OTHER 203 . 26 MASTERCARD TOTAL RECEIPT 203 . 26 CITY OF CUPERTINO C)o I ( 3 i` REROOF CU [NO PERMIT APPLICATION FORM APN# �� �ra {�� - Date: //f,� A� ✓ 1 G Building Address: Owner's Name: - �J Phone '2 ` — - � Contractor: Cc[ _ License#: ' C Z~ .� fit- Contact: Cupertino Business License #: �. Type of Roof Covering: Existing: Proposed: ❑ Built-Up Roof ❑ ilt-Up roof nphalt Shingles {e Asphalt Shingles 1wood Shakes ❑ Wood Shakes ❑ Wood Shingles ❑ Wood Shingles ❑ Other(Specify) ❑ Other(Specify) Number of existing coverings ❑ Provide I.C.B.O. Report# &"�T_o be Removed ❑ Provide Mfgr.Installation Specs. I Have Read,Understand and Will Comply With Cu ertino's Tear Off Policy: Job Description: S;kAdt_&s i 4-6 61,\-1, 6- C) �iLI t'rL? 6.1, a Residential Commercial ❑ Fire Zone: Yes ❑ No Confirmed with Planning Dept. if there are any restrictions: LJ Cost of Project:,F e of Construction: Occupancy group: t•Z- ` ice — Qty. if —Applicable • Fee ID Fee Description Fee Group BPERMFEE Bldg Permit Fees BUILDING BENERGY Energy BUILDING BSEISMICRE Seismic Fee Res BUILDING BSEISMICOM Seismic Commercial BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING 0c i G2 �. CITY OF CUPERTINO FURNACE/AC CUPEf_T1NO PERMIT APPLICATION FORM APN# Dat I: Building Address: - Z Cv Owner's Name: Phone#: Contractor: License#: Contact: Cupertino Business License#: Building Permit Info: Bldg ❑ Elect Plumb t_� Mech Job Description: Residenfial Commercial ❑ For Residential Inst Ilations: Attic ❑ 1'floor 2nd floor❑ Adhere to min set back requirement❑ For Commercial Installations: Replacement same weight E] Additional weight(structural calcs)❑ Structural Calculations required for new installation ❑ New installation Planning Approval Required Cost of Project: W Type of Construction: Occupancy gr�: Strapped On Platform Sed��­SqAtFloirBoArea: New Location ElRe lacement 7 Qty.if Applicable Fee ID Fee Description Fee Group BENERGY Energy BUILDING BREMFURN Relocation of Furngace MECHANICAL BREMACOVER A/C Unit> 10,00MECHANICAL BRENiAIRHAN A/C Units<=10, m MECHANICAL BREMRECEPT Recptl,Switch&Outlets ELECTRICAL BSEISMICRE Seismic Fee ResBUILDING EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMITFEE Mech Permit Issuance MECHANICAL MI PPERTFEE Plumbing Permit Issue PLUMBING BPERMFEE Bld Permit Fees BUILDING BPLANCHK Plan Check Fee BUILDING BUSLIC Business License BUILDING