04050013 CITY OF CUPERTWO r 9"s. ° '
Bmt.mrvc DrvlslON PERMIT CONTRACTOR YNFO$MATION •,,,
BuaDINGADDRESS: TENANT IMPROVEMENT PERMITN'04050013
99
ERS NAME: PERMIT ISSUE DATE
ETSUKO KURUMIYA O ALE SANITARY NO. CONTROL NO.
ONE:
(408) 866-1500
ARCHITECTAENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
Lop LICENSEDCONIRACIC3R'SDECLARATION JobDescri tion
w❑ 1 hereby affirm Ibut 1 am licenmd under previsions of Chapter 9(commencing p
UW whb Senion70r0)of Division 3 mf Ne Busimaxand Profession,C.&,and my license is
^Z'y imm�rameanaereot. REVISION--IN HOUSE USE ONLY
j y�z Liecnse Class Lac.as
Zoo Dam Contractor NO NEW PERMIT ISSUED/ORIG. #04Q40084
ARCHITECTS DECLARATION
1 understand my plans shall he used as public mcmfds
Oyu
Licensed Professional
oy
3 OWNER-BUILDER DECLARATION
I heathy affirm that 1 am exempt from be Contractor's License Law for the
r.0 O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
w y which mquims a permit to construct,alter,improve,dcmali,h,or repair any stmetum
FZa
poor it)its issuance.also mquims the applicant for such permit to file a signed statement
that he is licensed pursuant to the previsionsof the Conuazmr's Liam Law(Chapter 9 Sq.Ft. Floor Area Valuation $0
,FO (commencing with Section 7")of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the bub for Ne alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of APN Number Occupancy Type
oat mom Nan Eve hundred dollars($500). 31603039 . 00
❑1.as,owner of the property,or my employees with wages u their role compensation,
will do the work and thestmnum is not intended ofolfemd for role(Sec.Wan..Businem Required Inspections
and Prefassions Cade:The Contractors License taw data not apply m an owner of q p
pmpeny who Wildsorimproves thereon,and whodoessuch work himselforthrough his
or
Own emr,th ecs,p building
or Nm suchmerit is old within
not ear of omplodmd for owner. \
however,the building or improvement is sold within one year of completion,purpose
owner.
builder will have the burden of proving Nat he did not Wild or improve for puryom of
mlcJ.
1.as owner a ropeny.,B sinesivnd contracting with limedommitt ess i. \ \(7S
ounce Nc precut ( Oma,Business and ray whoons Code:)The Cs common, rid \\
whin not apply owner of property who Wilds m improve common,and \�
who. Inc man rejec nwiNacanuacmrts)liunsed pursuamm Ne Convecmta
L'¢c x law.
arrt exe t undo .B&P C far his mason
am
KER'SCOMPENSATION DECLA ATION
I h ruby der penalty of perjury one of the following dttlaratiou:
lhavea dwillm nminaCeniOcamof Consenuoelf-insumforWmkersCompcn-
u,ion,as p or by Section 370 of dm labor Code,far the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation haunt,,as required by Section
3700 of the labor Code,for the performance of the weak for which this pmmit is issued.
My Workces Compensation Insurance tamer and Policy number am:
Cartier. Policy No,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(nosseciim need not he completed lithe permit is formic hundred dollars($100)
or leu.)
1 certify Not in the performance of the work for which this permit is issued,1 shall not
employ any person in any manrmr m u w become subject to the Workert Compensation
Law.of California.Data
Applicant
NOTICE TO APPLICANT.If,after making Nis Cenificate of Exemption,you should
become subject m the Worker's Compensation provisions of the tabor Coda,you must
O forthwith comply with such provisions or this permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
E.. I hereby affirm that Nem is a construction lending agency for the performance of
ly'> the work for which Nis permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Lenders Add.
Z)z z 'fy the I have mad this application and sate that the above information is
lL collect.I ag a to comply with all city and county ordinances and sum laws mlating in
DU buildingcon coon,and hereby Achodm mpreatchadves of this city w cntar upon the
C[7 above-mention property for inspection iurpoms.
a to save,indemnify and keep hamdcss the City of Cupertino against 42
rn ]is itie,judgme .costs and expenses which may in anyway accrue against mid City
C)'� in consequence of granting of this permit. Date
A PLICANT UND STANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:
t) Re-roofs
manU mracmr V f UAW
HA RDOUS MATERIALS DISCLOSURE Type of Roof '
it thcapplica tar fumes building acupant Smmor handlchmudou mamdel
fined rttoo Municipal Cade.Chapter 9.12,and the Health and Safety
C.Section 25532(a)+ �l All roofs shall be inspected prior to any roofing material being installed.
]Yes til No
Will the applicant or future building occupant use cyuipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air conumimm.as dcEned by the Bay Area Air Quality Management all new materials for inspection.
ciannel'
❑Yesu
ave Neh:vaones matadals mquimmena under Chapter 6.95 of the Califon
'a calls&S Cock,$ 6..25505.25533ud253a.lunam=dNatifmc building
d not ovc a tenant Nat it is my mapomibilitY w nntil'y- a 'ant of the /
m theme' w oat be met prior to Viacome afs C.htifitam of . Signature of Applicant Date
o rAll roof coverings to be Class"B"or better
oma ori'rcJaFcnt D,