01060030U
R'
CITY OF
niERO No
CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS :
PERMIT NO,
21370 VAI AV
KADOKURA
KEITH AND MOSC
EL01060030
OWNER'S NAME:
APPLICATION SUB DATE-
KADOKURA KEITH AND MOSCHEL
06/06/2001
I PHONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INTO
LD ECT PLUMB ECI
L L J L -
LICENSEDCONTRACIOR'S DECLARATION
Job Descript' n
I hereby aRrm that I am licensed under provisions of Chapmr 9 (commencing
with Scdion ]000)of Division 3 of the Business and Profaxiom Code, and my license
Lt...full
C ars and effect. Lit. al
CONVERT
1 BEDRM. TO 2 BEDRMS.
Dole Canard,
ARCHITECT DECLARATION
1 be
understand my plans shelf i ual m public records
17
Licensed Prof ...ri sal
OWNER -Bu ILDER DECLARATION
(Bun that 1 1. exempt dram the Contractor C s Any a Law for the
1 hereby maso io Code: Any <ity or county
following reason ]031.5, Business and Profession,
,
ermitoIt
alter, improve, demolish. ,cram any structure
demolish.
de
requires a permit It)re cams
whichitsissuance
such fit,
.prion n '. nee.aW 9 � :tl applicant for such pens t( fl a signed statement.
tare
- -
- - -- - ----- --- - -
mmnetxl )sea ours t; clic pro ton: onhe comacmrx Lie xla (Chapmry
'esus
.a :, <Sq.,Fr.
`
Floor Area -!!,, •s $1T oation
J
(comm c g int Sm ]000) f D isian J of me Buunca d Profs Code)
t_ „ \, ; ,.
r
,
or that hers exempt therefrom and the basis for the alleged .aemiaion. Any violation
- of Sermon 703 1,5 by any applicant for a remain subjects the applicant a civil Penalty -
bN bT2l9
" Occupancy Type
Of not more than five hundred dollars (5500).
3 6
�) 0
❑ 1, as owner of the property. m my employees with wages as their sale compensation.
'
101
- FOUNDATIfrF9PWred Inspections;
will -do the -work; and the 'evucmre is not intended ' or offered for'xale (Sec. 7044:
Bror o and Professions Code: The Contractors License Law does ;rot apply to an
owner of property, Who builds or improves thereon, and who does such work himself
improvements intended
102
PIERS
or mroe h his own employees. provided that such are not or
-offered far role. If. however- the building or improvement is s.Id wimin one year -of
complehan,dt<owner-builder will have the burden (dousing that be did nor build or'.
.._ _
103
_ ... . - ----- -- ------ - —
- UFER .. , ,� •.
mprovefn rpaseorsale.).
__104..-..
REBAR
as Owner of the Proper, am exclusively contracting With licensed contractors to
ratan the peace, (Sir. ]BS4. Business and Professions Cade:) The Contractor's
105
- ANCHOR BOLTS ,t
,.
License Law docs non apply no an owner od property who builds improves thereon,
6
-.. SEWER & �...._.._
se
_.and wno.<onta<tx !m_ach Projecrs wird n cantaao0sl licensed pursuant tome.
._ .. _ _l0 .
.WATER. . _- ...... __
Comactorsu«nselaw.
❑ l am exempt under Sec. .. ;" ,,. r..B& P C for this meson
202
- UNDERFLOOR I.PLUMBING
Dwa T��- oa;e U/(0�0'I
203
- UNDERFLOOR MECHANICAL
COMPENSATION DECLARATION
204
- UNDERFLOOR FRAME
I hemby rffrm ander pommy of pc,,a ,,rte onhe following dedaaa(nx:
205
_ UNDERFLOOR INSULATION
0 1 have and Will maintain r'cemecate of Consent to xelf.msum for workers
301
- ROUGH PLUMBING
Compensation, as provided for by Section 37W of the Labor Code. for the
'perronnanm onhe work for which this permit ix issued. t,
302
- TUB & OR SHOWER
❑ 1 have and will maintain Wmkcr's Com,v mdimt Insurance, as required By Section
303
- ROUGH MECHANICAL
3]00 of the Labor Code. for the performance of the weak for .1ird'this remail is
ixxaad. My Workers compensatlnn imam;....o;ner,apd Fault In i.
r:-
_ -304._-
. ROUGH .._ELECTRICAL..--<�---,--.,---,--
c'ar`ne "; x •'F' - I .: policy Na_`_ —
' j'•-1' 305''-'
FRAMEq
r ' CEtorincAnobt OF E%EMPpioN rROM WORKERSl
CQMPENSATIONINSURMCE_.,
'
_3.06--
-
.-,HOLDOWNS-----^------------- — - ----------
_,` x ,' ...
'' (This dei'mi;amd rat be completed 'f nhe punt t \ furnace handned dollars
307
INSULATION I `
(5 100) onm,.l
"fir
_ - •--308
_ K _ ... _. ..
SHEETROC -__
'Wa1 en fy that is the perfo nce' Who workhich mux Perrot ;sauce, 1
'd worker.
309
c
- EXTERIOR 'LATH
li ,cat employ ay Pe in any krone, . . r become . hl t m me
Compensators laws of Califomih: Data " ...
-. .. 310-
- INTERIOR- LATH._
Applicant .. - ..
NOTICE TO APPLICANT: IL utie, making this Certifcxte of Exemption. you should'
311
- SCRATCH COAT
becamesubject m the Worker s Compensation provisions of the Labor Code, you must
rannwhn <(;a;py wird curb pr(visianx drift pcamh snml bed«;Wed rev(ked.
-- -
-'
313
I
- ROOF -NAIL .. . .... ... .. . --. - _ --.. .. -
CONSTRUCTION LENDING AGENCY
501
- FINAL ELECTRICAL ENERGY '
I hereby affirm that there iso c ass uciioai lending agency for the knfommnbe
one work for which nm4 pp mitt ixxpea (Sri. 3097, c....) "
__ ... 502--
-FINAL PLUMBING ENERGY-- - -
' Lender's Name"'
Lenders Address ;. ',
503
- FINAL MECHANICAL ENERGY
I certify that l have mad this application and.sta;e that me above information is
504
- UILDING ENERGY
limn. I oSme to comply with all city and county ordinances and data laws relating'
rebuildinI can strucnion. and hereby outhorize icpmsemdtivcs of this city m enter upon
505
FINAL LECTR AL
the above-menOpned pmpeny for inspection purposes.
(We) argue to save; indemnify and keep hardi the City of Cupertino against
50
- GAS T ST
liabilities. judgments• costs and expenses which may in any way aceme again, said;
hone '. .'
so
- UM G
City in <unimqueace gatmng ofihix permit. "
AND WILL'COMPLY WITH ALL NON- INT
.'APPLICANTUNDERSTANDS
SOI' ' E LLAT NS ,
Issued bar'
Date
(0 L O
Y/
Re -roofs 09
- F AL GRADE
Income of pp0< Commctm, . . .Date; '.
( ATERIAIS DISCLOSURE
HAZARDOUS M
' W 11 the applica t o forum bu Id ng occupmt stere a haralloux material
Type of�Mef,:-
INAL PLANNING ,
.. 2 ahaidle
dsdf dby th Cupen Mun opal Codc. Chapmr9l cad the Hwhn ands fay.
Code. Suuon.2]53Y1a)]'.,.•(L ''
5.14`'
, ,a, ,;
FINAL. PUBliIC,:WORKS
c lq'
0
❑Yx 0" '..t:• •' "'
._VAll.roofs.shall.
a inspected prior-to.any. roofing.material.being.installed.-.----
•.wmm<applicant Orrhoum building occupant use equipment or devices which
If a roof is installed -without first obtaining an inspection,' 1-agree,to remove
emit han, rd(us art conmmin"h;s as defined by the Be, Area Ail Quality Management
Districn^ •;•
all new materials
for inspection. Applicant understands and will comply
oYw ONO
gents
-with -
all non -point source regulations.,
I have re rdald hadntdoan materials q under Chapter 6.95' of the
'Cal ' is Health &Safety Code. Sections 25505.25533 and 25534: 1 understand men
if a Wit mg des nm curirn0y have b tenant. mat it is my mspomibility to notify tire
captain of the requirements which must be met Prior loissuance of h Certificate of
""pa"`y' -
Signature of Applicant
_ .. - Date
V�
All roof coverings to be Class "B" or better
Date
s ,. , D
net or turbanned! agent_
OFFICE .. .. ..
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