01080071 CITY OF CUPERTINO
nud.DiNG DIVISION
PERMIT :; ..CONTRACTOR-INFORMATION;,,_ _ _
BUILDING ADDRESS:' PERMIT NO. - - -
21171 CANYON. OAK .WAY.: _. . .. RICK IWAMOTO'. _
01080071
ALICTS8B
O15l2DATE O
PHONE: ... _ -, SANITARY N0. CONTROL NO.
Opo ARCHITECT/ENGINEER: BUILDING PERMIT INFO
�y BLDG ELECT PLUMB MECH
LJ LJ LJ L..I
LICENSED CONTRACTOR'S DECLARATION
b" Job Tnembyaft ma,1ranoftheBsidespndProfesrC,Code, lmmmenense Job Description
0HFu, wimSection 7lwoloromiamnlnnheen.ine..dnaProre..mn.coae.a,wmybaing ADD BATHRM IN GARAGE .
Y Y J Is In full force and effect.
tiO i U License Clu. Lic.g,
Dae S DECLARATION ��
ARCHITECT'S DECLARATION,
,g l,trinderuNial mypl' :hall INJ Dh[i,records
-,
adrpo L¢ dP fs- I ,
Re OWNER-BUILDER DEC LARAT ION
e w�y 1 hereby affirm that 1 am exempt firson the Contractor's L w �Law fur,he - -
Fz
following a (Section7031.5.Business dProfessionscol Any[tyorcnanty' ,r, .; " $31000 ! �"...
2=0 hich wmqu rc a perms, mnama,alto p :e a.mobsh terror any"fracture - s r
n 3= Mt , ,. c al. men .,n appl c ,f h pc t f R grind smmmem
shah - 1 c n J pars „ N pm o fm C t ,! L e I (Ch Pmr 9 3 .C9,,{.y,ft;:..,r tba Valuation
(c that
themboum and
Dbi.,n3oRbc Bminetincit Any,ns Code) "1' .7TV V7
or Section
e a he < pi m f m J the bass for,he es the exempt on Anriviola on -
of sdf a 7031.5 it a Y PPI I for a permnsublectv the aPPI c ,, civil penalty
,101 . ,. yiQ4�ATION Occupancy Type
,ofn ,room mao fveInitiated dollars(S51%Il Y APN'
01,as owner of property,or my employees wish wages as their sole compensation. - 102 I - ... _
Bus do m k- li m s, is n ,intended 'rs;fr d rot.,ale(Seeapply
voa+ 103 - UFER Required Inspections
ow s d erpfe i Cod ThContractor's License la d o,ork hi el .. ._ ._ .- _. ..._-..
owner
fproperty owne bull rap at d n encs en ,tn .mf 104,-- REBAR
' or,h ugh his own employees pros dcd that such-improvements sue no,intended or � � -, .
-oRFredfor.sthe. wtidwevd;,he buildingb1iniprovemmntnsold within one Weldof 105 --ANCHOR BOLTScamplet '
r improve for me owner builder will nave she buNcn of proving,M1m he did no,Wilder 106 - SEWER & WATER
improve for ptimrwe nr.me.l. - -
'_:: -d:a{owns of,Ac pmpenv.am exdu�ivclY comeactin ,h IlcenseJ comnic�os to `:-...
<nn.
- :. ma<tme Fw, _ 202 -- UNDERFLOORPLUMBING' -:•,"i: d.,-- , ' .
printer(sce.may B.,iae„and prof..im,Code:t The Cion, 2 03 - UNDERFLOOR MECHANICAL' .
License Law does no,apply to an owner of property who build,or improves themon. '
_andwho contracts for.such.pmjeco with a.commour 1.licensed pur,uant.w.the 204 -_..UNDERFL00R--FRAME-_.. . __._. .....
.: Contractor's License Law. . .. .. .. ... .......... _.
❑larrammorradersed. T• t"`;etircmrmi.aan 205 - UNDERFLOOR'• INSULATION
=' owaer' o �S'o / 301 - ROUGH PLUMBING
PENSATION DECLARATION 302 — TUB do 0R SHOWER
'�-� Ihereby afrnnunder pepahyofperi'uryone onhe.h,uowingdecmmfio°a' 303' - ROUGH' MECHANICAL
arta .
0 1 haves will mainuin'a Certificate of cpn.em ro self-maim for Worker's 3 04 ROUGH ELECTRICAL
Compeir,loon, as;provided for by Sea,idn l]W of the Labor Code, for the
'performance ones work fm which mix pemm•h awed. - 3 05 FRAME
°I base andwill,nainGin Woruer'i'Contpenw,ion Insurance,as i<quirN by Section 3 0 6 - HOEDOWNS' - -
3lW of the labor ew f m peri n< f mat work r ' hch m.,p man is '' 3 07 INSULATION
- rss tl My W-kefv C R t T r tt J policy n robe
r e.. „
err' p.'_.,i.., 308 SHEETROCK .:.,
CERTIFlCATION OF EXEMPTION MOM WORKERS( ;i" '. 3 O 9 -'I EKTERI OR LATH, 1
coHvcNgAnoNl-s ",11ce w -- 310 ';; -INTERIOR—LATH ".--'
r Rr tin ed not be complet J T the permit is f one hundred dollars
uunl R...l - 311 SCRATCH COAT
I nrym, smeperr.,at. nim kir b nm. pe .�<a.I .- 313 - ..ROOF NAIL—, t. .t, r. ,;•r- -- .. .-.
awn t ; ply nype.i manner , be.nn , BL ,tomtwnrken .- .-501-- ---FINAL-ELECTRICAL-=ENERGY--
�NCnmLx t nla nrcar ' .Dt - 502`x -..FINAL..PLUMB ING_„ENERGY . .- _-- _-
LmICETOAPPLICAM' if. mail ak gin C iris :fE' pt y n w 503 - FINAL MECHANICAL 'ENERGY
Z hi me wlb c,t the W ke C rope , pro,s ns m the Labo Call you musl
zC Tram me pyxim np ,nn.nrm nob a a evn a' 504-__- ,.FINAL-B.UILDING.,ENERGY.__
CONSTRUCTION LENDING AGENCY
”. 505 - FINAL ELECTRICAL
,Fye ] " 11 rcby fEtm,h i Ise ons , le ding age y f rhe p.c foram we `
'nnh kl - 9 m'h p< , s seaSer.'309] Civ.C, � 506' - GAS TEST
-L Q IcnJ N ml' - ._
'Leal Addr 507 FINAL PLUMBING - --- "--- -
v o 508 - FINAL MECHANICAL' '
I fIe ma 1 h as M pprc, J We,hash deo' 'naw,ro
E.r correct I grc , spy ,h Ile, nJ ntyod' est, 1 rvl,nog 509 - FINAL GRADE
t building'O n, ,a dh ny tmo p e ,isss City
,y, nmrppon as�
p thebomon, _edpopertyr spec, purposes. 510 - FINAL PLANNING
Val
liabilities.'W 1 g los ' nom (s and keep h I. the' f C pen' againstid
U Z ch c l , a. - t a p fthh n n y-, ny y g n„eaJ 514 = FINAL PUBLIC WORKS
APPLICANT UNDERSTA of NDS AND W ILL COM PLY W ITH`ALL NON-POINT
sovkcERP iiA ns�/I, '.,,�- ,� Issued by: 'Date
Stgmmr<
of AppbcaMComracctto`r"'s"^'•. Dace
Re-roofs .r ,
HAZARDOUS MATERIALS DISCLOSURE r,:
Will,hc yplica t r,mlwilding Occup, ,«e«.nasals nai tdPus mmeaal Type of Roof .
as delmod by the C pcnmo Municipal Cod Chaps 9 1 and the Health and Safer, ."'F'"'' ... ._- ,."••. .. -
Ciuk Section15532( P
❑Y P LYN f <y� ' _ All roofs shall be inspected pnor.to any roofing-material being installed..
Will the ire t alone building edoccupant <equipment a e.which If a root is installed without first obtaining an inspectwn 'I 3oree to remove
,h a r<om n. defied him B AeaA Qalty afmge , o
D" r 1 all new materials for Inspection Applicant understands and will comply with
all non-point source regulations ,. t .,
a Ihave red men N anal .. ._ .. .. _._ . .v f
q� ems arta Ch Pt 695 or th .__ .. .. .... . .. ._ . .. ...... . .. .
- C51 Torn a Heahn&Saf,y C.le.Sea ons_5505 25511 and 2553) I understand thvi -
ifmcbuildingdesnmcuemndyhaventenant,mai i,ii mW responsibility to notify the'
O«upam b(the requimmems u'hicn muss rte met prior,a i..nance of a Certificate of
Signature of Applicant-
Date
ti ow ermdn,nnnma agent Dam. . All roof coverings to be Class "B" or better '