01070146 (2) CITY DNGUP I
BUILDING
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO,
10315 VIRGINIA SWAN PL CONDITIONED AIR 01070146
OWNER'S NAME: APPLICATION SUB DATE
HOSHIZAKI MARIA I 164 B GILMAN AVE 07/30/2001
"Al
HONG: SANITARY NO. CONTROL NO.
( (408) 374-6311
no O ARCHnECT/ENGINEER: BUILDING PERMIT INFO
s m BLDG ELECT PLUMB MF,CH
LICENSED CONTRACTOR'S DECLARATION
'S w 9 1 hereby firm that 1 am licensed ender fCha Chapter (commencing Job Description
i Z=0 Y a Provisions a p g
mCm is in Sectiorceudefect. nn3nftheBusrnessandPmlcnsiansCode.andmylianm FURNACE CHANGEOUT
L Y j is in full farce rand effect.
i at aLicense Class Lic.p
O i O Date Contract-,
Ia.a. ARCHITECT'S DECLARATION
.5 . 1 understand my plans seal be used an public records
1 i p O Licensed Professional
OWNER-BUILDER DECLARATION
uai 1 hereby aRrae that 1 am,xcmpt from the Contractor's Licens law for the
following reason,(Section 7031.5.Business and Professions Cale:Any city or county
b 480
Y
FaF O which requires a permit nr construct alar,improve,demolish or repair any structure
pritem itse, I q thapplicant forsuchpvmino Eleasrgned so em,nt-. .
thatle2lc '.'dpnu ttotheD s nsofthe Contractors Lcenm Ww(Chapter9 gFi;.F'A�r•ffoaj,l -),, 1 Valuation
(uninteresting with Section 70DO)of D'vlsian 3 of rete Barrens and P pfyssi...Code) 1,4.'7.TL. l.� -or that he is except thc¢fmm and the basis far the alleged cambotimi.Any violation
of Section 70315 by my applicant fors pemdr subjects Neapplicantvil pen
a civil
arra,mate than E.e hundred dollars(ssfm). 301APN SII PLUMBIN Occupancy Type
Cl 1,as owner of the property,army employes with wages as their rale compensation.
will do the work.and be structure,is not intended or offered fur sale(St .7060,
Business and Professions Code:The Contmcmr's License Law does not apply to art 304 - ROUGH E) FANffR §§tions '
orowner th
of prapeny Who Wilds or improver dicrtom and who does such work himself 505 - FINAL ELECTRICAL
o,through his awn employees provided that such ve improvements is tens ane not intendedyear or
offered for sale. w howevere the building or improvement n sold within one Year of _completion,Ne awnerWime,will have the Wider of pmwmg that he dies nes Wua or 507 FINAL PLUMBING 1 '
improve for purpose of sale.). 508 — FINAL MECHANICAL
❑Las owner of the pmNA,am eulusively connecting with licensed comusicians to
omoram thc Miter(Sec.7040.Business and Provicions Code)The Contractor's r -
License law does nes apply m an Dine of property w W Wilds se improves pur 1.dha, r
end who amracte for such Projvua m
.with mracrogs),IicensW rsuant m die. ..- .-_.. ., A
Crounis01 mo om'sower License law.
' ❑Tem exempt order Sec. _� B&PCSothis maven
Owren Date 0 .
WORKER'S COMPENSATION DECLARATION C
r 1 hereby aRren under perol"of perjury one of the following declarations. O I M A 1_E D
1 have ata will maintain a Ceni6cme of Co... nes self-insure for Worker's
• 'ompcnsvtion, as provided for by Section 3700 of the labor Code, for the nrT 15 2001
peRomunce of the woh for which this permit is iuuW.
01 have and will maintain Workers Compensation Insurance,as ba ui¢d by Section
37M of the labor Code,for the perforrnana of the wank for which this permit is BUILDING 1 101 P1I p I/'�
is and,My War i's Coep,niation Insurance carie,and Fahey number are: U LD NG
Cun i 1 .1 Policy No..
CBRTIFl1
CATIONOFEXEMPTION FROM WOBKERS'l, •w.
.. . COMPENSATION INSURANCE _ .. . _... ....._.
(This secthWv imdnot be,aompleed if the permit is for one hundred dollars t�' ` '""' 1'•
I Certify that in the p inrifientrunceu of tb,work for which This permit a issued.I
shall not employ;any person in any mannv so as to become subject no the Workers •'
Compensation Taws of California.Dee
Applicant
NOTICE TO APPLICANT.If,after naking Nis Cenifi<a¢of Exemption,you should
Q Obncume mbject 1.Ne Worksotian Workers Cumpenpmvisims of Nr Lobo,Code,you moil
tormwith comply with such pon,kions or this pe,mit shall be deemed m—ont.
F '" 'nr•'• "'CONSTRUCTION LENDING AGENCY I '
' 'I heretiy affirm that them is a constitution lending agency for the performance
of the work for which Nis pamir is issued(Sec 3097,Civ,C.)
m
Q mch,"a Nae` _ _ .. -
u1. Z Ledde,'a Addresst ,
V , 1 certify that 1 have read this application and sure its the aWve information is
TanEs correct,l agree no comply with all city and county,ordinances and state laws relining
Q V to building conxuuction,and hemby'auttiorimmpieseinumses of this city to enter upon
W the above-mentioned property for inspection purposes.,
p„ (We)agree to save:iraemnify and keep harmless the City of Cupertino against
I,0 liabilities,judgments,co"'and expenses which may in any way amore against said
C.1.7, Ciry in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS. - - Y•
Signature of Appliam/Contractor Date' Re-roofs
ithr vIteranpeof-Roof. .. _... ,.. _ . . .. . ..
HAZARDOUS MATERIALS DISCLOSURE'
W01 theapplicant (ere Wilding occupant store or handle hassNws material Ty .-
as def ee by 25W( tn M nicipol Cade.Chapmr 9 12.and the Hwlth and Safnys i r i 1
cWe.Sa -
❑Yes- n
.. .. ...All.roofsfs shall be inspected.prior_ro any..roofing materia] being-installed. .
I
t-the applicant or furore building occupant tine equipment o,device:which If a roof is installed without first obtaining an inspection, I agree to remove
emit herardoas in,contaminants.defined by the Bay Arta Air Quality Management
Dvanin all new materials for inspection. Applicant understands and will comply with
❑Yea bNo all non-point source regulations.
.a
1 have need the MOa,dous matcnals requ6cmenta undo Chapter'6.95 of be
California Frahm&Safety Code.Sections 25505:]5533 and 25530.1 understand that .
if the Wilding does not currently haw,a mnam,that it is my responsibility to notify the
confirm of the requirements which must be mei poor to issuance of a Certificate of
occupancy'• " Signature of Applicant Date
Owner nr cuthorixcd agent Date All roof coverings to be Class"B"or better
-- r OFFICE