09050116CITY OF CUPERTINO
BUILDING DIVISION
BUILDING ADDRESS:
22284 PALM AVE
OWNER'S NAME:
PERMIT
RYOJI WATANAB
COr-rrROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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l °0 LICENSED CONTRACTOR'S DECLARATION b . :'" F. I hcn:by allinn thai I am 1iQ:...d under provisions nr Chaplcr 9 (commonc:in, Jo Descnption!~~ ..ith Section 7(00) or Division 3 or the B"";n... and Prorc:ssions Code. and my Iicell!C is
~~ e; in rull roo:c .nd clT""L REMODEL ( 5 2 6 ) STUDY, LAUNDRY RM, POWDER Rl1#5iADD 2 '.!~~ ~~~nscCILU ~~~I~-Io-r---------SKYLIGHTS EA. SMALLR THAN lOSQ.
~ ARCHITECTS DECLARATION ~~ ::;! I undcnland my plan••hall be usc:d as public records
lil!U
to. ...Licensed Prorcssional
OWNER·BUlLDER DECLARATION
I beo:by .mnn thai I .m excmpl rrom the Contractor's Lic:cnsc Lsw ror the
:°3 ~5 :s.00 rollowing reason. (Section 7031.5, Boai...s and Pror...ions Code: Any cily or counly ~~ ft which requires a permit 10 conSb1lC~ allCr. impro.... demolL'h, nr ",pair any SUUClureu-", prior III its issuance, .Isu "'Quires the .pplicanl ror such pennillo file • signed sLalCmcnl: 2;?<thai he is IicclI!Cd pUlSUanllo the provisions or the Conlr.ll:lIlr's wee... Lsw (Ch.pll:r 9 Sq. Ft. Floor Area Valuationi:: 0''''i (commencing with Section 7(00)orOivision 3 or the Business and Prorcssinns Code)or 4 a00 aei-thai he is exempllbcmrom and the basis ror the aUeged exemption. Any violation or
Section 703l.S by any applicanl ror a penni! subjeclS the applicanllD a civil pen.lly or f--------AP;-;;;;:N-;-;N:-;-u-m---;-b-e-r-------t--""""':<...:::..:::...:::.=O~c-c-u-p-an-c-y--:T=y,--p-e------
nol more than fi." bundred dollars (1500). 357 a4 a32 . aa
D I. as owner orlbc property. or my employees with wages as their sole compensation. L """":::-_-:-_:-:'-__~------------------
..ill do lbc work, and lbc .lnICIure i. nOI intended or offered ror.aIe (Sec. 7044, Business , • d I
and Prorcssions Code: The Conll2c1Dr's Lie.... L.w docs nol .pply ID .n owner or ReqUire nspections
property who builds or imPfO""S thereon,.nd ..bo doc••ucb work himselr or lhrou&h bis
owo cmployees. provided thai sucb impmvemenlS .... nOI intended or offered ror sale. If.
howe_.the building or improvemenl il sold within one year or completion. die owner·
builder ..iD IIlm: the burden or proving th.1 he did no' build or improve ror purpose or
..Ic.~
D I, as owner ollbe property, .m cxcIusively con~ing wilb licensed conlnlClOn 10
construct the project (Sec. 7044, Boain....nd Proressions Code:) The ConuaelOr's Li
cease Lsw docs nOI .pply ID .n owner or p<opcrty wbo build. or impro... lhcrcon, and .
wbo contraclS (or .ucb projeclS ..ilb a contraetor(.) licensed punu.nllD the Contractor.
License Lsw.
~~I~...~ex;e~p~l~un~der~S~e~c.~~~~~~~~~~~~~~~,,~~
WORKER'S COMPENSATION DECLARATION
I bereby alIil1ll under penally or peljury one or the (ollowin, declllJations:
D I tu;...and will maintain.Certificate or CoasenllD ..Ir·in.ure ror Worker.Campen
salion, as provided ror by Section 3700 or the Labor Code. (or the penonnance o( lbe
work ror ..hicb thi. pennil is issued.
D I b•." and will maintain Worker'. Compens.tion Insurance, as "'Quired by Section
3700 or the Lsbor Code, ror the pcrrormance or the work ror wbicb thi. pennil is issued.
My Worker'. Compenaalion I...",... curler and Policy number ....:
Carrier. Policy No.:=====-_
CEKTlFlCATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nol be complclCd i( the pennil is (or one bundred doDars ($100)
nr loss.)
I ccrtiry thai in thc perronn.nce o( the work (or wbich thi. pennit is issued. I sh.1I nal
~PIOY .ny person in .ny manner so OSlO become sqbjcctlD the Workers' Compcnsallon
A
NOTICE TO APPUCANT: Ir, .ncr making this CertificalC or Eaemption. you shook!
become subject ID the Worker'. Compensition provi.ions or lbe Lsbor Code. you mUll
rorthwilb comply with such provisions or this pemlil.ball be deemed .,.oIa:d.
CONSTRUCTION LENDING AGENCY
I hereby allinn th.lthere i•• construction lendinlagency ror Ibe pcrronnancc or
thc work ror which Ibis pennil is issued (Sec. 3097, Civ. C.)
t:~~:=~-------~------------~
I certiry th.l I h•." read this appliCllion and .late that the .bo." inrormation is
com:et, I .gree ID comply with all cily and counlY ordinance. and .",te I.... rel.tinllO
building con.truction. and be ",by authorba: reprcsen",~ or thi. cily to cnlCr upon the
.bo...·mentioned property ror inspection purposes.
(Wc) .gree ID ..... indcmniry and keep harmless the Cily or Cupertino 19ainst
li.bilities,judgmenlS,co and expenses wbicb m.y in any way .c=.gainsl said Oly
in consequence or the ling orthi. pennil,
APPLICANT UN TANOS' NO WIL COMPLY WITH ALL NON·POINT Issued by:
Date
Re-roofs
Type of Roof -w
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to removeWill the .pplicanl or r~lu buildinl occupanl usc cquipmcnl or devices ..bieb
emil h.,...aronu••ir conLamin.nlS defined by the B.y A",. Air Qualily M.n.gement all new materials for inspection.
District?
DYes No
SOURCE REG NS.
Signature of Applicant Date
All f coverings to be Class ':q." or better