01100148 CI
BUILDING EDIICiISSIIONNOPERMIT CONTRACTOR INFORMATION:
I
BUILDING ADDRESS: PERMIT NO.
1522 JAMES TOWN DR WATER QUALITY PLUMBING 01100148
OWNER'S NAME: APPLICgTION S B DATE
MACHIDA CALVIN T AND BETTY A T 1860 ALMADEN RD 10/29/2001
PHONE: (408) 267-9330 SANITARY NO. CONTROL NO.
D O ARCHITECTENGINEER: BUILDING PERMIT INFO
w
BLDG ELECT PLUMB MECH
as
omi i LICENSED CONTRACTOR'S DECLARATION
I tion 7 a)oro that 1"m licensed under provisions of Chapter 9(mmmccense Job Description
whnfalldoneandefDivinan3armega.mess maProfessions codeand myB«ns, REPIPE & MAIN LINE.
fYE is ecfallmics,and crccn.
i z m 6 Liccnu Claxs lie,p
O a O Dam Contractor
a OARCHITECT'S DECLARATION
1 understand my plans shall N used as public records
r
4_ e,O Licensed Professioal
n
OWNER-BUILDER DECLARATION
ii 1 herebymotto alarm on 1 oro exempt from the Contractor License Law for the
rn
i o whawmg reaoa. ,anion 7031.5.trimer andprofessions
improve,d m li code:rAnyepair or county $3000
which requires a Permit constmet, he p d ohsh,or repo r any smcturt
cal
i
m -pit t t c 1 q the applicant f h permit to file a signed statement - -- -- - - - "-"
that I dp" and 00) h of t t noes Ucenu .amarsapmr9 `s`� { 'In Valuation
(commencingexempt
Sectionmi and
Division 3 f m Holmes,and Prpfusy vi Code) [) 3 0'8'Y IY;(� .,�r9i ati}t,�'} "s•
a that io rs 31.5 b therefrom and the basis f m 11 the p lmpuod a civ violation t
of godson a than
iv any applicant for o permit subjects the applicant to o civil penalty
ornot mammanrvnhundred dollars(55oo). 202',,PNlt�48�FL00R IPL B'ING ' Occupancy Type
01,asowaerofineproperty.ormyemployeeswithwagesastheirsalecompensation. 301 — ROUGH PLUMBIN
G i
Businet[doss
me work.and the strucode:Th is not doesintended or a endLaw for snot apm.ply too n 502 — FINAL PI&tdl�4fd'iEdasr9NZ&GY
•Business and Prty Who
Gds:The Contractor's thereon.
License Law docs not apply io an
ownsofpropertywhobandsserimprovesmeuchiandwho d«ssatework nimsnf 507 — FINAL PLUMBING _
or mmugh his own cmplayees,provided mat such improvements as not mmided or ,--,
offered for sale.If,howuilde the building or int en of Flavin,
n Wird within one Year of
completion,the owner-builder will have the burden of proving that he did not build or
improve tar purphse of soled. :
OI,asowner of the property.ame usinesslacontractingwhithccoad co Contractor
. .. •'-.
construct the does
n (g¢,7844,Business end property
who
CNet)The improves
tan reon,
"! License law Wh nut apply to an owner lb.crony who builds as improves thereon,
and.who mmimu(a,such projects win a mmnnor(s)licensed pursuant to me _.. _ ...._ ._ ._ ... I. _. . ...
Convector's License law.
_ ❑len acmpt under Su. ,B&PCfor this moron •j'
Owner "ribm
WORKER'S COMPENSATION DECLARATION
I hereby uffou under penalty of perjury one of the following declarations:
Of have and will maintain a Cenificom of Conant to self-insure for Worker's
Compensation, as provided for by Section 37M of the Labor Code, for me
performance of the work for which this permit is issued.,_
O 1 have and will maintain,Worker's Compensation Insurane,,as required by Section
3700 of the Labor Code for the Performance Y the work for which this Perron is
ss J MyW k s Coahp,e..,sithou.lmmimm carrier andPolicy number are
CERTIFICATION
T3 ,EXE cr TIO ROM WORKERS' �` yi.4:�1'ih > i
h' ,COMPENSATION
INSURANCE ".... t . ..,.._.. ..._ -...- _..-.._....._.._..____._. ..-.._-..._.._�. _._ "_ .. _.-._ . .
pem,it is tar one napemd,nears "
(S 100)or less.).
certify that in the performance of the work for which this permit is issued.) . I' ' ""• ,^.',Y�u,v
shall not employ anyso
pern in any manme
marine,so as to beeline,subysh to the Workers
Compensation Laws of California.Dam,
-Applicant .
NOTICE TO APPLICANT!If.ides making this Ccnificate of Exemption,you should
0 become subject to the Worker's Compensation provisions of the Labor Code,you must
forthwith comply with such pmvisions or this permit shall Ise deemed Walked.
z!fq CONSTRUCT IONLENDING AGENCY -- - - 11
1 hereby i lTrm that Wert is a iommunion lending agaiiy mi the perfdrmonce
Le n k f which m s permil is issued(S JtNI:Civ.CJ u
ee Name
7,z Lender Add
Y, I cenify that 1 have mad this application and state that me almost,information is ,
'
I, F. correct.1 agree to comply with all city and county ordinances and state laws relating
Q:V to Wilding construction,and hereby authorize representatives ofthis city to enter upon
the alwve-mentioned pmusemy for inspection purposes.... ._ .
iFp, (We)agree tc save,indemnify and keep harmless the City of Cupertino against
i W liabilities,judgments.costs and expenses which may in any way acme against said
U'Z City in consequence of the'grhnning of this permit.'
r
APPLICANT
UNDERSTANDS
DS AND WILL COMPLY WITH ALL NON-POINTSOUR " I55ued by: Date
Slgnntme of AppllcanhCan Icor' ""' C - .. Dm<" Re-roofs
HAZARDOUS MATERIALS DISCLOSURE '
Will the appccant or future building occurporm sstore or hissib hawdoiu manorial Type of Roof
a def N by the CaliVeram MhWCIP4I Code,Chapter 9 12.and me Health and Safety
Code Stamm 25532m) ) r a, - ;i t l rte' ( �' �. 2 C `''i '.�1E %i �.: 1...:,1 - ... ..
❑res ❑No' " iAll roofs shall be.inspected.prior.to any roofing,material being installed.
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 Area Air Quality Management
Dislact all new materials for inspection. Applicant understands and will comply with
1:1 via, Oberall non-point source regulations„
I have mad'ma bazallous m"enals rcgdirerthenm under Chopmr'6.95 of me
California Hcahh&Safety Code,Scitions 25505:25533 and 25534:1 understand that
ifiha Wilding docs not currently have a tenant.that it is my responsibility to nmifythe' - -
owspam of We requiamentb which most k met prior to issuance of a Certificate of
Occupancy. Signature of Applicant Date
-.'l. Ownet ormahminAagent Date All roof coverings to be Class"B" of better
i OFFICE
CITYBUILDING DI�VCfISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
1522 JAMES TOWN DR WATER QUALITY PLUMBING 01100148
OWNER'S NAME: APPLICATION SUB DATE.
MACHIDA CALVIN T AND BETTY A r 1860 ALMADEN RD 10/29/2001
PHONE: (408) 267-9330 SANITARY NO. CONTROL NO.
ARCHITECDENGINEER: BUILDING PERMIT IN
— BLDG ELECT LUM MECH
LICENSED CONTRACT'OR'S DECLARATION
"S y- 1 heeeb farm that I am licensed maker r i f Cha mr 9lei mmeneirt Job Description
�i_a ya pov sionso P 8
yr ad whnsectitnvddo)troieiaitn3nnheet.memmandntremmmnmCode and mybernme REPIPE & MAIN LINE.
m tall rorme a Ir i I -
a O cd U manse ass Lic,g
c 3 m 'am- Conm semr
.p RCHITECfS DECLARA I
1 understand my plans shall be used as public records
f3
c.87
Licensed Professional
al OWNER BUILDER DECLARATION
uKi="i 1 hereby affirm that 1 am exempt from the Comoram'x License Law for the
t?< following mason.(Section 7031.5,Business and Professions Code:Any city or county $3000
E x a which requims a permit to construct,alter,improve.demolish.or=pit my smuaum
pmj3gv _pri t t els req ' the pplicam for tach pcnri uo nleengnmd smmmem .. -.. -_. re_
Nat be slcensed pun Ant to Cheprovisions of the Comracmrs License Law(Chapter 9 .C..1.har.,,RirlmrA Va21 . p !!� , Valuation
(co e g wh Secfont]BUO)pf D"son Sof the Business and Professions Code) C..C.Jst i coq. i_ y f,rrt,�l fill.
PRO -
0,
that he rc exempt themGom and the bans orate allegd eiwptma Any violation
of section 9031.5 by any applicant fora permi,subjects the eppbcam toe civil penalty
of not mom than five hundred dollars(s5d0). 202APNtWS'ERFL00RIPL BI'NG" Occupancy Type
01:as owner of the propsry,or my employees with wages as their sole compensation.
willwill m the work,and the stricture is mmcoo's Li or offered for uof(Sec.taw.' 5 0 2 - FINAL P11Uk &1l1Qsf@N@RGY
d.is and Professions Code:ur The Committers Licor Low does not apply 0 m "
owner of property Who builderimprovemthereon, oil who does each work himself 507 - FINAL PLUMBING
or through his own employees.provided thus such improvements arc not intended os
,olfered 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.).
[11,asthe
ofNep(Secny.am Business
and Professions
Cade:)
Cuacmrsm - - A'
consumer
!
Linens et the project(gee.,two,owner of and atywho Galen The tes tmemeh F I N A L E D
License Law diem not apply m m Owner of a c my who builds or improves thereon,
and who's Liceta for such projecm.with a commnorts)licensed pursumtm the -
01 a.a.rs License Law.
❑1 am exempt under Sec:' '' BA P C for this reason
. . N�OV`0 7 2001
- WORKER'S COMPENSATION DECLARATION
' Ihereby affrmunder,Kus!gofpdrjuryone tf,hafollowing declarations: BUILDING
0 1 have and will'maintain'a Ccnilcae of Consent tu alf-insure for Worker's
Compensation, as pmvided for by Section 3700 of the labor Code, for the
performance of the work for which this permit is issued.
01 have andwill Coupe set o l i mace q red by S tin
3 of the Labo Cod f the rformance of diwork fo titch this pcmutis
s d My"W r at t Wt� s r ca d policy. be m _
C o Iyy
Policy No f 'l'("s 5,1:. �e,i'i lY .e ,,y s1 ^.5��'JIT.. 1'i.l.l.•f
CCRTIFICATIONDFEXEMPTIO OM
,, COMPENSATION INSURANCI!
('flucn
s siim i'ed not be,completed if the permit is for one hundred dollars
(E100)or
1 cenify that in a n f Qh k f which M ct t o unused 1 t t, `
shell ar employ w, person ar any manner so as.to become subject m,Ne Workers
Aplilm ration laws of Celifomia:Darr.. .
'bNOTICE emmFrTOAPI!LICANimIf,eti aBctmakfng Nle Ceninsof of Labor lod,yuhmuld
0 O becomeh comp m the Workers Compensation provisions of ed erred Code,you must
(onbwiN comply with such provisions or this permit shall be deemed mvok<d.
Ln ""';CONSTRUCTION LENDING AGENCY . . -
, a'> " ' I hereby affirm that Nere'is'a communion lending agency for the rerorrance " '•'
. W of and work for which this peanit is issued(Sec.I09T,Civ.C.)
Q (cadets Name..
Li
V'l� T unify that T have used Nis epDlication end state that the above information is
o t..i correct.1 agree to comply with all city and county ordinances and nam laws relating
0(V on
building construction.and hereby amhotlze'representatives of Nit city to enter upon
the Omm-niminkmedreality far imilclunPurposes.
, ,
F q (Pre)agree msave.rodemnify and keep harmless the City of Cupertinoagainst
W liabilities,judgments,costs and uKromx which may in any way accrue against said
f, City in consequence of the granting of Ni.i permit' ^ ; " '
APPLI NT UNOEtSTpNDSANO WILL COMPLY WITH ALL NON-POINT" Issued by: Date
SOU EREGUTATIONS. y'
tue.fApphemsemieacmr "i' " ..•..' . .' .Date',; Re-roofs '
r t HAZARDOUS MATERIALS DISCLOSURE
(.
Will Nr pplicant or future budding oauPmt It.or bused],bazmdous material Type of Roof
as defined by the C,q,snino M pal Cade 1 9.12.and Ne Health and Safety
Code Section155320 t Ut';
OLAll rololfG s�,s{altli :ehb ,t
r t ,
inspected prior to,any roofing.material being installed. ,. --
Will the liplj<snt or future buildingoccupam use equipment or devices which If a roof is installed without first obtaining an inspection, I'agree to'remove
emit hazardous air crimaminanis as defined by the Bay Area Air Quality Management
District+ all new materials for inspection. Applicant understands and will comply with . .
❑Y x .f, _ ,❑Nt' all iron-point source regulations.
a,'read Ne h za dous mitenals mgmmmems mide,'Chapter 6.95 of the
Cali to HealthVCode,Sections 25505;25533 and 25534..I understand that _
if building cmmndy have mnmLNat it is my,a,,..,ibility to amifythe -
isaim f i wh h sun tic mu prior m is p tt'of C<n
P dicem of
y .. -
._.Q Signature of Applicant Dale
Ow ramhorizmd grnt,-
All roof coverings to be Class"B" orDam
better
% O y
FFICE