08090154 (3) CITY OF CUPERTINO BUILDING PERMIT
It 1i11:I11NC mm it f:SS: 1641 POPPY WAY (:(m'1'RACIOlt: BROTHERS HOME vi:ioi TNo:08090154
1IM11R0VI7MENT
owml iz'S.N,kmr,: YOSIIIKAWA SAM M AND CONSTANCE 2510 DOUGLAS BLVD i)XI t ISSUE[):09/24/2008
OWN'EwSIII IONE: 4089961747 ROSEVILLE, CA 95661 PnON'F.NO:(40x)295-06x0
❑ LICENSED CON*TR:%CI'Olt'S UFCLAR X TION' r r r
BUILDINGI'I?It>II'I'INFO: IMAX; F.LF.CI' rLuaun
License Class Lic.k r r r
?Ili CII RISSIIW.SA IAM. (]U\L,ICIWIM,
Contractor Date
JOB DF.SCRIP HOA': RITLACH 14 WINDOWS k 2 PA'f10 DOORS LEM;FOK I.IKIi
I hen•br al'linn that I ani licensed under the previsions of Clr,pier 9 S'I'RA tall I Kli'PK0 F11'INS'I'A 1.LA HON
(aunnwacina,with Section 701111)of Division 3 of the Bu,ine„& I'rufessiuns
Code and that nv license is in full fin'ec and el'I'rcl.
I herebc all]rIll under penalty of perjury one of the I'ulloving nvu der]:u'miuns:
I have;aid will maintain a certificate of conscnl to self-insure lir Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the teork for tchich this permit is issued. Sq.III Pleur Arca: Valuation:$11000
I have and will maintain Worker's Compensation Insurance,tis provided lox be
Section 3700 of the Labor Code.for the perhmnance of the work liar tchich this
AI•\\'umber: 76615038.00 Orrup:uacr'I'rpr:
permit is issued.
APPLICANT Cl?lt'I'IFICA TION
I cerlil'y(hill l have read this application and state that the above information is PERD'II-I' EXPIRES IF WORK IS NOTSTARTED
correct. l agree to comply wills all city and county ordinances and state lanes re ling W 1.11.11 N IRU DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize reprcsenmtiveS o]lhiS city to tiler
upon the above mentioned properly for inspection purposes. (We)agree to save 180 DAYS FROLM LASTCALLED INSPIiCTION.
indemnify and keep harmless the Chv of Cupertino against liabilities,judgments,
costs.and expenses%%)lith nue accrue against snit]City in conscqucnec of the
granting of this permit. Additionally,the applicant undersuutls and trill comp]\ ISsoc'(I b1': Iinle:
with all non-point source regulations per the Cupertino Municipal Code.Section
9.18.
It&ROOFS:
Si_Linure Dan: All rook shall be inspected prior to any roiling material being installed. If a roof is
installed wilhoul first obtaining an inspection,I agree to renimc all new materials lox
inspection.
❑ OWNER-It1111,DPat DECLARATION
Signature of Applicant: Date
I thereby affirm %hal I :un c,rmpl from the Cuntraclor', License Late]'ur one of
the fullo..'ing Ecu reasons: ,\1,1,ROOF COVrIt INCS TO III:CLASS",\"OR 1W]'ITR
L as owner of the property,or my employees with wages as their sole compensation,
do the cork,rand the structure is not intended or offered for sale(Sec,7044,
Business&Professions Code)
L as owner of the propenyl am exclusively Contract] with licensed co Ira s-m IIA%AIMOUS)IATFRIAI.s D ISC1.OS1iItr
construct the project(Sce.7044,Business R Professions Code). I a".r .0
the hazai dot,materials requirement,under Chapter 695 of the
Ct It, Ia I Iealth\Sufl'I,'Colic.Sections?55115,25533,and 25534. I ill
I herebc affirm under penally ofyerjure'one of Ihr full , • re Frmli +compliance with the Cupertino Municipal Cede.Chapter 9.12 and the
declarations: Tdlh&Sarvt,Code,Section 25532(a)should I,lure or handle hznu'duu,
I have and will maintain a Certificate of Conse sel, ns f V( es lilacrial. AJJitiun:dly,should 1 use equipment or devices which emir hazarcho,
Compensation,as provided for by Section', of It 1 or 11
,for i11A air Coll%anti nit its as(left tied Di.Iricl I
performance ofthe work for which this pe 'I is issue �C will maintain compliance with the Cupertino,\l unicipad Cute.Chapter 9.12 and
I have laid will maintain Worker's Cnmpens, t -era c, r (led for by the I Icahh&Safety Cute.Section,255115.'_5533,and 25534.
Section 3700 01 tile Labor.Code,for Elie perfnr ocr I t a war Iia which this
Owna'r ur flnlhmiZr•(1 anent; Utile:
permit is issued.
I certify that in Elie performance of the work ha wine this permit is issued.1 shall
not employ any person in anymtanner,o as to becon+c subject m the Worker's
Compensation]ties of Califnnhia. If,alter staking this certificate ofexenhplion,I CONti TR HC`] I.I SUING MAINE')'
become subject to the Worker's Cool pen slit ion provisions m'the Labor Code.I must I hereby affirm thin there is a construction lending aecncy for the perimmanec of
fonlm ilh comply with such provisions or this permit shall be decried revoked. %,ark's Ior which this peon il is issued(Sec.3097,Civ C.)
Lender',\aloe
APPLICANT CE RTI FI C\'1'1(1\ Lender's Addri•s,
I ccnify that I have read this application and Sete that the above information is
correct.I agrte to comply with all city and county ordinances and state Imes relating
to building construction,laid hereby authorize representatives ollhis city to enter
upon the above mentioned property for inspection purposes.(WO agree to save :Ut(:III'I'ICCI"S DECLARATION
indemnify and keep harmless the City o1'Cuperlino against liabilities,Judial cels.
costs.and expenses tchich may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additional]\',the applicant understands and will comply
with all non-point source regulations per the Cupcnino Municipal Code,Section Licensed Professional
9.18.
Signature Date
CITY OF CUPERTINO
OF
CUPEkTINO GENERAL BUILDING
PERMIT APPLICATION FORM
APN # Date:
{SLP 5' 0 0� 9124 o8
Building Address:
1 by I `po,py wa
Cu pe�a.o q at
Mailing Address (if different from building address):
Owner's Name: Phone� #:
Sam v astir Kww n 006) q
Contractor: Phone: or,So
Fax:( 66)-xg5-3`lga
Contractor License#: loq q 009
Cupertino Business License #:
Contact: Seo r\ iso,i Phone:(yp*,)59 �•3b5 7
Fax:
Residential Commercial
Job Description:
_c,.e F 6 ly w r c{owS `� a t>n-1'vo floor,
I-!�L YOr t-1Ic�
Building Permit Info:
Bldg Elect ❑ Plumb ❑ Mech ❑
Type of Construction (Usage Class): Occupancy Type:
1-A, I-B ❑ II/III/V-A ❑ 11/111 B, IV-HT, V-B \�
Valuation: 000—.o Square Footage:
Project Size: Express D� Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building/LEED Checklist & attach it
to the application or if applicable, include in plan set & the sheet index.
Points Achieved:
For help, contact Build it Green at www.buildit reen.or
Revised 7/01/08
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