12100134 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21079WIIrrEFIRCT CONTRACTOR:ONE DAY COMPLETE PERMITNO: 12100134
REPIPE
OWNER'S NAME: SIIINO IARA KAZUMICIII/MICIIIYO 662 N 12.1.11 ST DATE ISSUED: 10/172012
OWNER'S PIIONE: 4085065794 SANJOSE.,CA 95112 PfIONE NO:(408)603-0554
❑ LICENSED CONTRACTOR'S DECLARATION rt
BUILDING PERMIT INFO: BLDG r— ELECT — PLUMB Q_
License Class /2 C, Lic.9 pig 5 2 _ r rl r
/ DIECH RESIDENTIAL COMMERCIAL
Contractor Dale/ O—1,Z—/ Z
1 her affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: RE-PIPE ENTIRE RESIDENCE AND REMOVE AND
(commencing with Section 7000)of Division 3 of the Business S Professions REPLACE
Code and that my license is in full force unit effect. THE WATER HEATER IN SAME LOCATION
I hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,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 provided for by
Section 3700 of the Labor Code,for the performance of die work for which this Sq.FI Floor Area: Valuation:$5000
permit is issued.
APPLICANT CERTIFICATION ANN Number:35905069.00 Occupancy Type:
I certify that l have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and slate laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the 6ty'of Cupertino against liabilities,judgments.
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant underslandsand will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section /
9.18.
Signature Dale /p Issued by: _��,�/V z �T Date:/V-17-1
❑ ON NER-RUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Lawfor one of All roofs shall be inspected prior to any roofing materialbeng installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and die structure is not intended or offered for sale(Sce.7044,
Business S Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business E.Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Cenificme of Consent to self-insure for Worker's MALA RDOUS MATERIA IS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health S Safely Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilcalth S
Section 3700 of the Labor Code,for the performance of the work for which this Safely Code Section 25532(x)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Qualily Management Dislricl I will
I certify that in the performance of the work for which[his permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ileallh S Safely Code.Sections 25505,25533,and 25534.
Compensation laws of California. If,after making(his cenificate of exemption,I
become subject to the Worker's Compensation provisions of[he Labor Code,I must Ow I 'z n
forthwith comply with such provisions or this permit shall be deemed revoked. Da(e:<��--z---�—/
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify,that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,mW hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accme against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional
12 / vul 3-LI
GENERAL PERMIT APPLICATION M E f
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION ,
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255 w A I
SC
CUPERTINO..ff (408)777-3228 • FAX(408)777-3333 • bulldlnafCDCL'DerInO.OFCI
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STR=7- AD'DRESS /. I CITY,STATE, ZIP �J FAX
❑ OWNER ❑ OWNPR-BO'L'DER ❑ OWNER AGr "-e. -I CTDR ❑CONTRACTOR AGENT, ❑ ARCH== ❑ENGDT�EEX ❑ DEV'_OPER ❑ TENANT
CONTRACTOR NAM' LCENSE NUMBER co 9 21 L6
(� CENSE TYPE /„I BUS.LC%
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AR CIiITcCf/ENGLNEe'R NAME LICENSE NUN✓SER BUS.LIC 0
COMPANY NAME' E-MAR FAX
STRS?ADDRESS CITY,STATE,ZIP I PHONE
USE. OF aSFD m DVPLEX ❑ MU FAMILY PROTECT IN WSDLWD ❑ 1 zs PROSECT DI YES Is TnE BLDG AN ❑ YM
BUTT-DING: 'O COMMERCNL URBAN INTERFACE AREA NO FLDOD]ANE NO Dl]iL-R HOME/ 1A NO
DESCRIMON OF WORK T
TOTALVALL'AT10N: Q 0
RECEIVED BY:
By my signature below,j certify m each of the follo viig: I am the properY owner or authorized agent to act on the property owner's behalf 1 have read this
application aid the information I have p is C=CCL I have read the Description of Work and verify it is accurate. I agrea m comply wdLh all applicable local
ordinances and sax laws relating m' d'* onstrvcdon. I zutborze re rives of Cupertino to enter the above-iden"d'�fied pmpe;,y:or inspecion pufposes.
SignanItzof Apilicant/Agem: Dam: A / T
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
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OVER-THE-COUNTER
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❑ NWOR
AE?.kfucApp2011.doc revved 06121111