06070098 CITY OF CUPERTINOmwrsua �§ , as:4 adv '''�i " '
MI
12
BUILDING DIVISION PERT CONTRACTOR INFORMATION
,: «
BUlu
ING ADDRESS: KOGACHI WAYNE AND CHEN JI N006070098
RS NAME: PERAQT ISSUE DATE
KOGACHI WAYNE AND EN JI-CHI
E:
SANITARY N0, CONTROL NO.
ARCHITECTfENGINEEIC BUILDING PERMIT INFO
BIRO EIECf PLUMB
MEC
I�
ioa LICENSED CONTRACTORS DECLARATION Job Description
F 1 baeby"M Nu 1 w U-1-1 under povi.iona a Chapter 9(mmmn g p
i z�W NW Seeuon T000)af MvUioo 7 of Ne Budnen vA Pra(eunm Code.and toytlttna It /
;�i Llal¢u�m circa uc. HOUSE DEMO
F� Dae Cauaaa
ARCHITECTS DECLARATON
iii ItuticrB.od my pWuandl be uaW upebtic record. �/�/��
�u
',o LkcnuJ Pmfo.iaol
OWNER-BUILDER DECLARATION
<3 1 hertby.Rum on I.m.11-1 fmm dte Coio(.%h,.Cot Lireme Lim f«Nc
O o folbvin'rovaa.(Saute TU]IS.Budav and nm. lomtm C«Ic:Any my a away
7 9 vhkh roqulrts.Permit o .« tbol.dla,knr.mm,m cO-oil,a a{mU toy
:Zr Pri°rm fu iet'u^te..4 mtol`t No.tuopm f«wmi toilet ilea U,,(Chcwu
k.lia�dPudmmweofDiu rilix ortbBam,.L .lav 9 Sq.Ft. F7oorArea Valuation
(eotM 111 pihSe 700B)a lowo,for
of the Bulneva400.My mComa
�.. Ih-W i.hemp Nemfma aw Ne bui.r«me wnw uemptlm Ani„Ilwtian a
seabn TBl IS by AM ppR (a I Pandt wb)ew N<-PPUatt m.eau P®hYa APN NVAUeF U V Occupancy Type
ver mort duo fie himdreE dollu.(55(311
❑1,u owrcr of de prvpeny,a my empbyeea whh�a�o u Ne'v aolc mopvu.dm,
ww mlhc•.mh.wo:-The mecu Li,,,U.clo ri ILpp«.TfMl.euvav Required Inspections
pm,and oty wnau Code The Co for nda Lav dm mt apply m w awx-a T�
mom to/vW WipvAdO thorn anm..ndabo doo4t wathwOffiabm$Nh4
awn aopry bo "x 1pnmcb im itolaootaitoot,v.omdaaBerod fa vlc,,
Wild&r.dutoo uto a h or
'thOtde iill. rit a caople,I .dteauer -
Wk.). NU haw Nv Muden of poNn�dtal be did ttn Wit a iaprmv fa potpx a
akJ.
L u owe-a Ne Properly.•m nclnt�r onuaalnL with UQ ued movactors b
cououn Ne pmjea(Sec.TObd,Bndrtea and Pmfecuau Code)The Caa.aa z l;-
anu 1..dere eat.Pgr to m owns of KOPcnr who W Itit a impm.0 ttravn,c .
.bo coom la webpoje vBhacmu.emrtU lianxd po,=ot m the Ctnu Ws
Llan-Law.
I.rnioto ourWa See .BBPC(athurea.m
g/z '06
ORKER'S C MPFNSATION DECLARATION
1 y.IMo under Pvulty a PuJory omadr foBVWn daJmums .
.,.e oMillii I.
naCenifiae of Cant b CO&,ire opoll aCampo-
vuon,u prmided fpt by Section 77110 a ttr labor Code,for Ota perfamwa of the
wak fa wiiab Thu permit u 1.we6
❑I bue ak will maintain WO Ues Compenutba IoPu.na,u rNuimd by Scctinrl
7700 of dto L tba Code,fa the pvformance of the wit fa v Nu Permit a Wne1
My Workees cotprm.uoo bra arric Policy numba.rt:
Caner: Polley No.:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE -
Cnti..n:tivooi nm W comPkrJ if We Permit u for arse hundred hoWa(5100)
a leu)
1 wufy Nat in the pvfomurta of Ne r for which Nb Permit u iuoed,l ahaR out
cmployuy Rrtonin.nym.one[�up pecwte wbjectm NCWatua'Caopt=u .
fowl a C.LifOrMIL WK 1� D=GV
NOTICE TO APPLJeANT.If,.faa making this Ccrifimm Of Ewnptico,you ihouW
became tubjac m Ne Wa z Comw=tion poviinou of tW lube-Code."mom
,JO (aWwith comply wWil hP"idau a Nup it Nall bo damcd matrff
z CONSTRUCTION LENDING AGENCY
1h roby.lf tba Nero u.emervctimt lending. y fa Nc po-f«nunauf
thew for which thu permit It mss ISM 3097,Ci..C)
�Q tromla Nano .
z Lerdch Addrev
U O I Mrdfy N.t I het rod Nil JLWICnlan 1104 roto Na Ne abme iofoto Woo U
U. P c«aa I.,roe to canply w all ciry tale coumy aNim.and rvto u Nadu{to '
C U Wildins cone oo,mid Mc y.uotmn rcpt nuii. .f Nu city to cnmr upmn Nc
W above-wouatod pmpc y ra KcOon purpor
(Wt,).g.to vm io&moifY.nd keep lurmleu the City of Cupertino aL.iou
„H„h Il.bllitlet Juderocw,ca.0id pita ahicb wy N.ny w.y.. it].uid City
U.Z In coucytctoe of the 1r LO(J.1 a Thu Permit /r v
t-" APPLICANT (UNNNDDTEERRSSTSANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date / /-'
S1,. EG/A/� /�G L-i� 6"I��j IO rfi
6/ Re-roofs
sl{ of Ap H.VContacwr Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIU Nc.pp0at or fumro WIMiag aavWt.wrc or batNc h.amu OO=id
by Ne Cupenion Mutmlpd Code.Chapter 9.12 aaq dtc Ho1N and Safer
.Section 25532.)' All roofs shall be inspected prior to any roofing material being installed.
❑Ya ®No
Will Ne.ppllc.nl«rtrtWc mdw;n�attvpaw=ewiplttm amain which If a roof is installed without first obtaining an inspection,I agree to remove
.it hvuNnu dr Contami.u dcfmd by the Bay Aro Au Q.ullty Mana{cmcnl all new materials for inspection.
DivriaT
CYa ®Nu
have rc W the bv�mwdsdh mi,mmmcw under Chapmr 6.95 of the Cilifa.
Ma FbIN 65.IdYCom.Sauom]3505,25531 am1235J4.1 unM1mv�d Ihadto b
lfuikiq
Jeer mt cvmndy hate.tm.a.Na it a my rtipon.ihllitY b mdy tW omrpwt of the
tryabc whish m<t a.cmraaro �OG Signature of Applicant Date
ow r wtW .etas t mto All roof coverings to be Class"B" or better