02100160CITY OF CUPERTINO
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CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUI"6,'@9ESSTEVENS CREEK BLVD
YAMAOKA GEORGE AND MISAKO
PERMIT1,102100160
DWN�€,T*L40KA GEORGE AND MISAKO
APPLICATIP15SNBZy3TY2002
PONE:
SANITARY NO./ CONTROL NO.
ARCIn'niCT/IiNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 o a
LICENSED CONTRACTOR'S DECLARATION
1 hereby affirm Inas 1 am lmened ander Pro+i:ion.. or Chapter v (commencing(commencingrIng
J b.DCSCLIOD
s P
METERFU
wish Section 7m10) of Division 3o! Ne Business and Professions Code, and my license is
9 ,.G } ji
in lull force and 'ff.'.
Licrnsc Class Lic. N
Date Conlmc'N,
OCT J 1. ZOOZ
ARCUm'C*rs DECLARATION
1 understand my plans shall be used as public records
BUILDING
Licensed Prom,siona'
OWNER DUIm DECLARATION
In fl Law for the
1 hreaso (sec that cxampt from the fessinsCos Any
$100
:
o CnJe: Any city
reason. (section 7oJstru business andProfessionsc
. 1. uunry
whichfollowing
utter, improve, demolish, structure
demolish,
which inquires a improve. de repair anyawment
io re cores
o lien a signed smmmem
also inquires the,inin applicant for r fi
to s e.al the
censed
39g6H0If1�3A@@
Valuation
tpoor hat h Contractor's
thatheitpareuamlathepmavwiMooftheComsinssandProetawlGbapmr9
l p
(commencing with Section 700(b of Divisionlof the Business andon.An vi Code) 0'
Net W is exempt Nemfrom and the basis for the alleged exemption. Any violation of
PN N Occupancy Type
Section 7031.5 by any applicant fin a remit subjects the applicant to a civil penalty of
not mom doEva hundred douatafs5a).
301 - ROUGH PLUMBI sJG
❑ 1, as owner or IW property, or my employees with wages as their suit compensation,
will do the work, end the etruaum is bol intended or offered far sale (Sec. 7014, Business
RfiERat
Clulre nspecllons
and Professions Code: The Conuacmr's License law units not apply lir an owner of
506 - GAS TE
propeny who builds or improves thereon, and who does such work himself or through his
Own employee,,. provided but such improvcmcms am oat intended ornfemd for sale. If,
507 — FINAL PLUMBING
however, she building or improvement is sold within ane year of completion, the owner -
builder will have the burden of proving that he did not Wild or improve for purpose of
salt.).
0 h axr of the properly am exclusively contracting with licensed contractors to
contact the pmjecl (Sea 7044, Business and Professions Code:) The Contracmr's Li-
cenxc law docs not apply In an owner of property who Wilds or improves lhemon. and
who contracts for such projects will a..hrtles (a) licensed pursuant to the Contractor's
License Law.
1 am a lit gder, Sec. B& P C for this reason
Ow Dat�V
�JDRKER'SCOMPENSATIOND ATION
the atom under Penalty of perjury one of the following declarations:
1 have and will maintain a Ceni foam of Consent to aelLinsum for Worker's Compen-
salion, as provided for by Section 3700 of Jit labor Code. for the Performance of the
wnh for which this Permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, u required by Section
1700 of the Labor Code, for the performance oT the work for which this pennit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Carrier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Oris daction need bol beeomplemd if tW permit is for one hundred dollars(SIMS
less.)
I certify that in the perforoup,- of Ne wnh for which this permit is issued, 1 shall not
employ any Person in anhe Workers' Compensation
Laws of Calti«�ii. Da w• d
App 4Eay dd t —
NOl'I T A QA IL of ler matin this Ccnilicam of EacmPlion, you should
beat c subject I Ih• WII ers Compensation provisions of the labor CnJe, you must
forthwith comply With such provisions or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm than there is a construction lending agency for the performance of
the wo k for which this permit is issued (Sec. AND. Civ, CJ
Lender's Name
Lender's Address
I certify that 1 have mad this application and stale that the above information is
carrea. l agree to comply with all city and county ordinances and state laws reluti ag to
building construction, and hereby amhodm representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities.judgments, costs and expenses which may in any way accme against said City
in comeyucnce of the granting of this permil.
Date
APPDBS,AN1 UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: l�
SOU R ULATIONS. •(,)-73—p
Re -roofs
Type Roof
oat IicanUConuacmr Dam
HAZARDOUS MATERIALS DISCLOSURE
of /
Will the applicant of future building occupant store or handle hazardous material
as dcE tied by the Cupertino Municipal Code, Chapter 9,12, and the Ilcallh and Safety
code. Section 25532(a)?All
roofs shall be inspected prior to any roofing material being installed.
C] Yes ja�No
If a roof is installed without first obtaining an inspection, I agree to remove
Will heappliranlOr( future buildingoccapaarmacgoipmenlordedms Which
mail thatandous air contaminants as defined by the Ray Arco Air Quality Management
all new materials for inspection.
Distria7 �11
❑Yes
1 have read the hvaNnus mmcrialswcluimmcnu under Chapter 6.95 of Ne Califnr
nia IPcalNdt Sufefy ClJc,Sadnns 25A15.255JJ end 255J4. 1understand Nulif Nc NoUmg
doe cu"'al' haat a ten ant that it is my meprnchility m ninny lbe acipxm(if the
alai rant hchn,a.IWmefpdotloissaanceolaCcnifeam Ocr ary.
Signature of Applicant Date
(Date
All roof coverings to be Class "B" or better
rte m a imaasenl
OWNER -BUILDER VERIFICATION
1. (Check one) I or my immediate family (parent, spouse or child) 0
A. %c All the work authorized by this permitL!jl$e
2002B\ A portion of the work
C. None of the work
If B or C is checked, complete 2 or 3 below.
2. A state licensed contractor will be hired to do:
A. _ All of the work
B. _ A portion of the work (complete section below)
Contractor Address/City
Phone # State License # Type of work to
be performed
/ 3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
portions of the authorized work. I understand that I may be an employer (see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Number I Type of work to be
I declare under penalty of perjury that the above is true and correct.
Owner -Builder Information (r verse side).
Property Owners Signature:
Job Address: (`t � we
I have read and understand the
Date: /G --Q�^ 02,
Permit #
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
• Department.
Ili (�-0
CITY OF
CUPEI�TiNO
Dear Property Owner:
City of Cupertino Building Deparhnei
10300 Tone Avera
Phone: (408) 777-3228
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner -builder you are the responsible party of record
on such a permit. Building permits are not required to be signed by property owners unless they are
personally performing their own work. If your work is being performed by someone other than yourself, you
may protect yourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work, with the exception of various trades that you plan to subcontract, you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family, and the work
(including materials and other costs) is $200 or more for the entire project, and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer, you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding, federal social
security taxes, workers' compensation insurance, disability insurance costs, and unemployment compensation
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers' compensation insurance.
For more specific information about your obligations under federal law, contact the Internal Revenue
Service (and, if you wish, the U.S. Small Business Administration). For more specific information about your
obligations under state law, contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale, property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees, without a licensed contractor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner -builder
building permit, erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they arc performing
their own work personally.
Information about licensed contractors may be obtained by contacting the Contractors' State License
Board in your community or at 1020 N Street, Sacramento, California 95814.
Please complete and return the enclosed owner -builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department, •
City of Cupertino
Printed on Recycled Paper