04040084 CITY OF CUPEWHNO ..,
BUILDING DIVISION PERMIT CONTRAC lORINFORMATION ;
❑HIL DING ADDRESS: PERMIT N00 4 0 4 0 0 8 4
1
990 HOMESTEAD RD
F.R'S NAME: PERMIT ISSUE DATE
v
ETSUKO KURUMIYA 14 2004
JNE: SANITARY NO. CONTROL NO,
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG E
CLECT PLUMB MCCII
t�
r0, LICENSED CONTRACTOR'S DECLARATION
To 1 hereby affirm that 1 am licensed undo provisions.(Chapter 9(commencing Job Description
^mawith Section?000)"r Division 3 of Tc Busincxs and Professions Code,and my licmnse is ��t���a{1l1 A��®
y in mu fnrecandefren. TI- -MUSIC STUDIO
License Clus Lie.le
Dale Contractor-
ARCHITECT'S DECLARATION JUN 7 2004
Sa I understand my plans shall he used as public records
o aruu
C y Licensed Prnfcssional BUILDING
ay
9aa g Y
OWNER-BUILDER DECLARATION BUI DING
Q2 1 Wrchy affirm that I am exempt from The Contractor's License Law for the LL/
0 o following reason.(Scctiun)IRIS,Business and Pndessloru Code:Any city Or county
<$ which requires a porton to construct,alter,improve,demolish,or repair any structure
'LIQ pnoflnits issuance,also requires the applicant ror such Permit thea signedslawrocol
£ that he is licensed punuanI to the Provisions of the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
_0 (commencing with Section 7")of Division 3 of TW Business and Professions Cotic)or
i that he is exempt Ihcmf ion slid IT,basis for the alleged exemption.Any violation of
Section 703 1.5 by any applicant for a Permit subjccu the applicant to a civil Penalty of 314 R3xR14l9cr0 0 Occupancy Type
not more Orion give hundred dollars 45(X).
0I,as owner of the property,or my employees with wages M their sort,compensation,
will do the work,and The structure is not intended or offered for sale(Sec.7044,Business
and Professions Code:The Conmclor's Liceitm Law dao not apply to an owner of Required Inspections
property who builds or improves Thereon,and who doessuch work himself or through his
own employees,provided that such improvements are not intended or offered for sale.It,
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 Wild or improve for purpose of
salt.).
E)1,as owner of The property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business and Profusions Cade:)no Convacwrs U.
carne Law does not apply to an owner of property who Wilds or improves thereon,and,
who contracts for such projects with a contractor(s)licensed pursuant to Ne Contractor's
License Law.
1 am exempt under Sec. .B&P C for This moon
Date /u. 0
J� ^/ �WORKER'SCOMPENSATIONDIi ATION
I hereby affirm unties penally of perjury one of the fallowing dechati imus
I have and will maintain a Certificam of Consent to m
self-insum for Worker'sCopen-
sation,as provided for by Section 37M of the Labor Code.for The performance Or the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,ss required by Section
37B)of the Labor Code,for the performance of the work for which this Permit is issued.
My Worker,Compensation Insumme cattier and Policy numher arc:
Canicr: Policy No.; -
CERTIFICATE OF E%EM MON FROM WORK ERS'
COMPENSATION INSURANCE
(This acclinn need not W compleled if The Permit is formic hundred dollars(g HgB
of less.)
1 sanity that in the perforrearse of the work for which this Permit is issued.1 shall not
employ any pcfsmn in any manner so as to become subject a the Workeni COMP,cmi tinct
Laws of Califurnie.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
,Jz forthwith comply with such provisions or this Permit shall the deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(-.14 I hereby affirm Thar there isa construction lending agency forint,performance of
a > the work for which this permit is issued(Sec.31NT7,Civ.C.)
W Q Lenders Name
z Lender's Address
U C) 1 ecody Nat 1 have reed this application and toxic that the above inro mnion is
W P corecn.l agree To comply with all city and county ordinances and stale laws minting m
O U building construction,and hereby authorise npresenuliws of this city To enter upon the
Lc above mentioned property for inspection prMoses.
F+ (Wt,)agree 1.save,indemnify and keep harmless the Ci Ty of Cupertino against
y liabilities,judgments.costs and expenses which may in any way accrue against mid City
U z to consequence of the granting or This Permit. /
r. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT - Issued by: Date
SOURCE REGULATIONS. "I f"-D0
�id�kt �GD)✓ ,n .ems Re-roofs
Signature of ApplicantlComvactor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future Wilding OauPant store lir handle hanNuus material
To lied by the Cupertino Municipal Code,Chapter 9.12.and the Health and Safety
tie.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ERN.
Will the applicant or future building occupant use equipment or devicos 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 Ortho
I havereed the Wvafdoue 2550olsrequirementsunder Chap¢rfial Ofthe Wilding
iia Healthu Safety haw
aSsmand.But
it i my respriabi4.l understando Ovocthe Wiring
tiro not currently haw a tenant.Nm iT is my sespouihility m notify the arupenT lir the
regeremenkcwhichmua be met Primrm iamance run certireatc tar Ocempmey' Signature of Applicant Date
is iter or emmmr&eti ages, D,re All roof coverings to be Class"B" or better