01070072y.+
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
841 ALDERBROOK LA BUDGET PLUMBING 01070072
'9T'991WURA SHIZUKO 28695 ROANOKE ST lyPP%IfAll /N�leU 1
PHONE: SANITARY NO. CONTROL NO.
(510)303 -7847 •
Z ARCHITECT(ENGINEER: BUILDING PERMIT INFO
O
p BLDG ELECT PLUMB MGCH
uo L— C_I IL CI
z, LICENSED CONTRACTOR'S DECLARATION Ob De$Crl tlOn
I hereby affrm that l am licensed under provisions of Chapter 9 Lumnmencing WATER HEATER RE; LACEM NT .
m with Section 70001of Division 3 of the Business and Professions Cede,md my license
is in full force and effect.
U License Class Lie, tl
y Dam Contractor
ARCHITECT'S DECLARATION
I undersmnd my plans shall material; puhim mmrds
OLicensed Professional r
OWNER - BUILDER DECLARATION
m 1 hereby affrm the I nm exempt from ibe Contractor's License Law for the
oll —iug «nsun. (decd en 70;1.5, Busact,, and Pr °fexxions Cede: Any my or county $650
C) which requires a pemrie e° comwct, almr, improve, dnnofsh, o, repmr any slrvcmie
m .. prior to its issuance, also requires the applicant for such permit to file a signed statement
1
— [h Teased pu on Abe pro Division the Ce Businc and Professions Cods) 1 368312 :Rrn1110or a, s 7,, Valuation
or (commencing M9 i urnmid 6vsonarthealegede exemption. Professor n ,�t t ._ !, ,PYY �,.4 •. t.l_f#
or that tio 7 31.5 by therefrom middle basis for the alleged exemption, Any violation "
of not Section than iv any applicant for a permit subjects the applicant to a civil penalty t
,,f not more thanfvenrrneredemraralssom. 502ARNpI�$k7�gI, PLUMBIN ENERGY Occupancy Type
°I, as owner of the property, or my employees with wages as their sole compensation, 506 — GAS TEST
'willnessa- Prumso ehestructure Crat intended
en offered far sale (See :7Ban 507 — FINAL PL agW�fspections
Business and Professions Core: The Contractor's License Law does nm apply e° elf
owner of property lo, a em builds er improves at such thereon, and who does such work himself
ore red for hu own employees. y provided th t h p es are within ar or ....... ..... ..._ __ ..__ ...... _..
-" comply for sale If, er iM1 building at improvement r e vi Id tdidone year of
o"mmfn the owner -builder Ie.) will have the burden of proving that he did not build or
improve for pu[pose of wleJ. j
0 Las owner of de property amt elo rvely mmmc[ing ca ..'.. ._.. .. ....__ .._ _....., .. ._.. .t
w th Idenseh contractors to
nsnse the eajen (Sec Ito a, Business and Profession Code:) The Contractor's
License Law does not apply man owner with property who builds seimproves t to the
..end who remodels for such projects wieM1 a.enntructor(s).licensed. pursuant to. the . .......... .._. J _... ...,._ . ... .... _.
C t t License Law.
❑tm mtundeSC effiPCfonhixrensup PIMALED
O Dde "
WORKER'S COMPENSATION DECLARATION
I hereby ofrmand,,pen.¢y,o'perjury one of the frl.wmg deductions: OCT U 3 2001
° I have nd will maintain,a Cedificme of Consent to self - insure for Worker's
Compense,rion, as provided for by Section 3700 of the Labor Code, for the BUILDING
performance of ehe work far which this permit is issued. ,
° 1 have andiwill maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cede, for the performance of the work for which this Permit is
is dMy Worker's Compe sat nn lnsu' wrrerundPl y bran:
'noter Policy f4 s t`
CERTIFICATION OF EXEMPTION FROM WORKERS a'
COMPENSATION INSURANCE,
fTh dsenion eed not be completed if the permit is for one hundred dollars ' .I
ISloO) or less.l
,. :.. .. _ _..,.. ....._,,. .. .. his, 1
dim, ploy ct er per f any ma of the work for which this p a is issued, Workers
I
�c6ci not employ any person m any manner so as td become subject to the Workeri
Compensation fnws of C°lifornlu, Dnto.
.Apphcani_-.- CANT. a _....,. .. ... ....._ .
•NOTICE TO APPLICANT. 11, after making this Certificate ofExemption, you should •
becomesubjectmthe W'orker's Comns on, ton provisionsll edeehor Cute, you must t
� f°nhwith comply with such provisions or this permit shall he deemed revoked.
"
"CONSTRUCTION LENDING AGENCY '
I h by thin 'bill pe '. a construction t Sag agency for the Performance f .. .
e Leaner', Name whmh [h pens a n „ssueJ IS 3097, Civ. C.1, ... x .. ... ... ... .. .... _...... -. ' ............ .._ __.. _... _. ..,
., ess ...
Lender's Addr' .
yI tfm ne a deb application udset that is information pro n
correct, l g t comply with IP city d, ty d m J state s minting k If
rob building [ t dh bye [h p nwtive fth city,. m pot
ll eh M1n e mentioned . property a t inspection purpose,
y e, pug is m save, n ad expe and keep hi hammy in ,by le °from a wino against
liabilities, judgmeina, costs and n, of to i which may in any way accrue againss said
� C'ry' nse9uence bt'th g Ming of 1h s VL I - '
APPLICANT UNDERSTANDS AND WILL COMPLY'WITHALL NON- POINT' Issued by: Date
SOURCE 'REGULATIONS. v' s ,
Signature' of Appl'mmVComractor ” 'Date" - Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W Il ehe aapplicant f m building occupant t earn dl Ile N usm te'sl ,.Type Of ROOF-
as defined 2 C ip Munii pal C d Chapter 9.12, den Health and S f tY -
Cod Section 25532(a) � .' � - ( -
�'' All roofs shall be inspected prior i 1 i s -• .
7
°Y' „ ' ° "° r to. any, roofing material being installed...._ . .
Will the ppli m t r f t building oaupam use eq p e e ie�a which If a roof is installed without first obtaining an inspection; I lagree to`remove
emth rtl .a'rcet ants asdefind by the Bay Area Air Quality Management
District? all new materials for inspection. Applicapt•tinderstands and will comply with
all non -point source regulations: -
I have ad he hazardous mmerinls� requimbems under Chapter 6995 of the
California Health k Safety Cede, Sections 25505,' 25533 and 25534. 1 undersmnd chat
-... ..
if the fgdoes
quiru have a writer, that prior my responsibility of ionficat the -- 1
occupant f the requ es hich must et,p prior to i.. f a Certificate of '
Occupancy
OFFICE
'... _. .. .. .' ... .:._..
Signature of .,, Dale
,Applicant,.,,,, ...... , -_ -.
All roof coverings to be Class `B" or better
o �, mserzed agent ,• . Date
y.+
CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
841 ALDERBROOK LA BUDGET PLUMBING 01070072
'9T'991WURA SHIZUKO 28695 ROANOKE ST lyPP%IfAll /N�leU 1
PHONE: SANITARY NO. CONTROL NO.
(510)303 -7847 •
Z ARCHITECT(ENGINEER: BUILDING PERMIT INFO
O
p BLDG ELECT PLUMB MGCH
uo L— C_I IL CI
z, LICENSED CONTRACTOR'S DECLARATION Ob De$Crl tlOn
I hereby affrm that l am licensed under provisions of Chapter 9 Lumnmencing WATER HEATER RE; LACEM NT .
m with Section 70001of Division 3 of the Business and Professions Cede,md my license
is in full force and effect.
U License Class Lie, tl
y Dam Contractor
ARCHITECT'S DECLARATION
I undersmnd my plans shall material; puhim mmrds
OLicensed Professional r
OWNER - BUILDER DECLARATION
m 1 hereby affrm the I nm exempt from ibe Contractor's License Law for the
oll —iug «nsun. (decd en 70;1.5, Busact,, and Pr °fexxions Cede: Any my or county $650
C) which requires a pemrie e° comwct, almr, improve, dnnofsh, o, repmr any slrvcmie
m .. prior to its issuance, also requires the applicant for such permit to file a signed statement
1
— [h Teased pu on Abe pro Division the Ce Businc and Professions Cods) 1 368312 :Rrn1110or a, s 7,, Valuation
or (commencing M9 i urnmid 6vsonarthealegede exemption. Professor n ,�t t ._ !, ,PYY �,.4 •. t.l_f#
or that tio 7 31.5 by therefrom middle basis for the alleged exemption, Any violation "
of not Section than iv any applicant for a permit subjects the applicant to a civil penalty t
,,f not more thanfvenrrneredemraralssom. 502ARNpI�$k7�gI, PLUMBIN ENERGY Occupancy Type
°I, as owner of the property, or my employees with wages as their sole compensation, 506 — GAS TEST
'willnessa- Prumso ehestructure Crat intended
en offered far sale (See :7Ban 507 — FINAL PL agW�fspections
Business and Professions Core: The Contractor's License Law does nm apply e° elf
owner of property lo, a em builds er improves at such thereon, and who does such work himself
ore red for hu own employees. y provided th t h p es are within ar or ....... ..... ..._ __ ..__ ...... _..
-" comply for sale If, er iM1 building at improvement r e vi Id tdidone year of
o"mmfn the owner -builder Ie.) will have the burden of proving that he did not build or
improve for pu[pose of wleJ. j
0 Las owner of de property amt elo rvely mmmc[ing ca ..'.. ._.. .. ....__ .._ _....., .. ._.. .t
w th Idenseh contractors to
nsnse the eajen (Sec Ito a, Business and Profession Code:) The Contractor's
License Law does not apply man owner with property who builds seimproves t to the
..end who remodels for such projects wieM1 a.enntructor(s).licensed. pursuant to. the . .......... .._. J _... ...,._ . ... .... _.
C t t License Law.
❑tm mtundeSC effiPCfonhixrensup PIMALED
O Dde "
WORKER'S COMPENSATION DECLARATION
I hereby ofrmand,,pen.¢y,o'perjury one of the frl.wmg deductions: OCT U 3 2001
° I have nd will maintain,a Cedificme of Consent to self - insure for Worker's
Compense,rion, as provided for by Section 3700 of the Labor Code, for the BUILDING
performance of ehe work far which this permit is issued. ,
° 1 have andiwill maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Cede, for the performance of the work for which this Permit is
is dMy Worker's Compe sat nn lnsu' wrrerundPl y bran:
'noter Policy f4 s t`
CERTIFICATION OF EXEMPTION FROM WORKERS a'
COMPENSATION INSURANCE,
fTh dsenion eed not be completed if the permit is for one hundred dollars ' .I
ISloO) or less.l
,. :.. .. _ _..,.. ....._,,. .. .. his, 1
dim, ploy ct er per f any ma of the work for which this p a is issued, Workers
I
�c6ci not employ any person m any manner so as td become subject to the Workeri
Compensation fnws of C°lifornlu, Dnto.
.Apphcani_-.- CANT. a _....,. .. ... ....._ .
•NOTICE TO APPLICANT. 11, after making this Certificate ofExemption, you should •
becomesubjectmthe W'orker's Comns on, ton provisionsll edeehor Cute, you must t
� f°nhwith comply with such provisions or this permit shall he deemed revoked.
"
"CONSTRUCTION LENDING AGENCY '
I h by thin 'bill pe '. a construction t Sag agency for the Performance f .. .
e Leaner', Name whmh [h pens a n „ssueJ IS 3097, Civ. C.1, ... x .. ... ... ... .. .... _...... -. ' ............ .._ __.. _... _. ..,
., ess ...
Lender's Addr' .
yI tfm ne a deb application udset that is information pro n
correct, l g t comply with IP city d, ty d m J state s minting k If
rob building [ t dh bye [h p nwtive fth city,. m pot
ll eh M1n e mentioned . property a t inspection purpose,
y e, pug is m save, n ad expe and keep hi hammy in ,by le °from a wino against
liabilities, judgmeina, costs and n, of to i which may in any way accrue againss said
� C'ry' nse9uence bt'th g Ming of 1h s VL I - '
APPLICANT UNDERSTANDS AND WILL COMPLY'WITHALL NON- POINT' Issued by: Date
SOURCE 'REGULATIONS. v' s ,
Signature' of Appl'mmVComractor ” 'Date" - Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
W Il ehe aapplicant f m building occupant t earn dl Ile N usm te'sl ,.Type Of ROOF-
as defined 2 C ip Munii pal C d Chapter 9.12, den Health and S f tY -
Cod Section 25532(a) � .' � - ( -
�'' All roofs shall be inspected prior i 1 i s -• .
7
°Y' „ ' ° "° r to. any, roofing material being installed...._ . .
Will the ppli m t r f t building oaupam use eq p e e ie�a which If a roof is installed without first obtaining an inspection; I lagree to`remove
emth rtl .a'rcet ants asdefind by the Bay Area Air Quality Management
District? all new materials for inspection. Applicapt•tinderstands and will comply with
all non -point source regulations: -
I have ad he hazardous mmerinls� requimbems under Chapter 6995 of the
California Health k Safety Cede, Sections 25505,' 25533 and 25534. 1 undersmnd chat
-... ..
if the fgdoes
quiru have a writer, that prior my responsibility of ionficat the -- 1
occupant f the requ es hich must et,p prior to i.. f a Certificate of '
Occupancy
OFFICE