07010173 CITY OF CUPERTINO
� R� O R Z QRMATI€3i�1•
BUILDiNG'DIVISION PERMIT CTOR
BUILDING ADDRESS: PERMIT NO.
I TE
OWNER'S NAME:
YASUHO MIYAKAWA 360 MEMJRIAL DR STE 140 01/29/2007
SANITARY NO. CONTROL NO.
)NE:
(866) 293-3031
BUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
p a LICENSED CONTRACTOR'S DECLARATION Job Description
t m r- I hereby affirm that I am licensed under provisions of Chapter 9(commencing
Y z w with Section 7000)of Division 3 of the Business and Profession ode, my license is WATER HEATER 40 GAL GAS
H in
t p Daftuclsfoe and of
Classj4? LicenLic.M
Contra
ctorev CIS
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AR
DECLARA ON
aa I understand my plans shall be used as public records
�aU
W ti Licensed Professional
=�< OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
00 following reason.(Section 7031.5,Business and Professions Code:Any city or county
PL which requires a permit to construct.alter,improve,demolish,or repair any structure
u z y prior to its issuance,also requires the applicant for such permit to rile a signed statement Valuation
that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area $500
yy.t=- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
i that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 6931015 . Number Occupancy Type
not more than five hundred dollars(5500).
❑1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractor's License Law docs not apply to an owner of
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered 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.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
❑I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑1 have and will maintain a Certificate of Consent to self-insure Cor Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issuedlo
W rkees Compensauon Ins
/W�apcc ccaarri rand Policy number are:a [ / / �OlicvNoCERTIFICATE OF EXEMPTION FR OR COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dolla
or less.)
I certify that in the performance of the work for which this permit is issued,1 shall not
employ any person in any manner so as to become subject to the Workers'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Oforthwith comply with such provisions or this permit shall be deemed revoked.
Z • CONSTRUCTION LENDING AGENCY
[�Q0. 1 hereby affirm that there is a construction lending agency for the performance of
> the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
Lender's Address
U 0 1 certify that I have read this application and state that the above information is
Lt� H correct.I agree to comply with all city and county ordinances and state laws relating to
0 U building construction,and hereby authorize representat0cs of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
Hto liabilities,judgments,costs and expenses which may in any way accrue against said City �7
U Z in consequence of the granting of this permit. Date �
"- AP ICANT UNDERSTANDS A WILL COMPLY WITH ALL NON-POINT Issued by:
SO ULATIONS.
Re-roof:;
tgnarurc of hcant/Conuactor Dare T Of Roof
HAZARDOUS MATERI S ISCLOSURE Type
Will the applicant or future building oc store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roof 3 shall be inspected prior to any roofing material being installed.
❑yes No
Will the applicant r 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 all new materials for inspection.
District?
❑Yes o
1 have read the hazardsus materials requirements under Chapter 6.95 of the Califor-
nia Heal &Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
docs notrrcntly have a tenant that it is my responsibility to notify the occupant of the
requircm which mug be me orwisswnce Certificawof=u�an gignatu)eofApplicant Date
.Q- L All roof coverings to be Class"B" or better
Owner or ocd agent Daic
rir
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408)777-3228
` CITY Of Fax(408)777-3333
-UPEkTINO
Buildin De artment
JOB ADDRESS: `)2; PERM
OWNER'S NAME: PHONE # Z -
GENERAL CONTRACTOR: FAX #
I am not using any subcontractors:
Si;nature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass/ Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
CITY OF CUPERTINO
3 ITEMS OF 6 PERMIT RECEIPT OPERATOR: suew
COPY # 1
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 36931015.00
DATE ISSUED. . . . . . . : 01/29/2007
RECEIPT #. . . . . . • • • : BS000000338
REFERENCE ID # . . . : 07010173
SITE ADDRESS . . . . . : 10345 FARALLONE DR
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : YASUHO MIYAKAWA
ADDRESS . . . . . . . . . . .
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : RECEIPT INTERFACE
CONTRACTOR . . . . . . . : PAUL HENDRIXSON LIC # 27607
COMPANY . . . . . . . . . . : PLUMB IN TIME INC
ADDRESS . . . . . . . . . . : 360 MEMORIAL DR STE 140
CITY/STATE/ZIP . . . : CRYSTAL LAKE, IL 60014
TELEPHONE . . . . . . . . : (866) 293-3031
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BENERGY PERMIT FEE 1.00 34.86 0 .00 34 .86 0.00
BPWHEATER PER HEATER 1.00 10 .79 0 .00 10 .79 0. 00
PPERMITFEE FLAT RATE 1 .00 38.37 0 . 00 38.37 0.00
- --------- ---------- ---------- ----------
TOTAL PERMIT 84.02 0 .00 84 .02 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- --------------------
CHECK 168. 04 1271
---------------
TOTAL RECEIPT 168 . 04
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
502 FINAL PLUMBING ENERGY 506 GAS TEST
507 FINAL PLUMBING
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