05050033 CITY OF XPERTINO j77 au 7'7' " ..... t��` ,
BUILDING DIVISION PERMIT (CONTRACTOR;INFORMATION
BUILDING ADDRESS: PERMIT NO.
CRW INDUSTRIES 05050033
NER'S NAME: PERMITBSUEDATE
ME:
SANITARY OL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
= O O D
i
00 LICENSED CONTRACTOR'S DECLARATION
ZC 1 Mreby affirm that 1 em licensed under pmviaieos or chchowr 9(mom prem, Job DOSCrIphO
<U with Section? Mryar Division 3 of Jur Business and Protesaiom Cndc.end myliccnsc is ���®
in full farce and effec
5�� L;cen�LK.sZ1Z� REPLACE 5 'WINDOWS/1 PATIO D tltl
z'O Da. Contractor
E',j' ARCHITECTS DECLARATION
yet s< I understand my plans shall he used re public meords S fg 2005
JyV
;off Licensed Pmfcssional
S OWNER-BUILDER DECLARATION
Conte ON �S8 y8�®�
i I hereby affirm Nol I em exempt from dm Contractor's License law for the Iµ�J.�Or 4pD�lut
o O following mason.(Section 7131.5,Business and Pmfesaions Crum:Any city or county
which requites a permit m construct,idter.impmve,demolish,or repair any sweom
NG
prior w its issuance also requires dm applicant forsuch permit to file a signed statement
-�a that he is licensed pursuanuo the prnisiomof the Contractor's License law(Chmee,9 Sq. Ft. Floor Area Valuat rin
yls-O (commencing with Section 7000)of Division 3 nfthc Business and Professions Cosec)tar
y Nhm
at he is exempt tefmm and the that for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty of 3 I j{q$�er0 0 Occupancy Type
not mom Nan five hundred doll..(I500).
❑I.u owner of time Properry,a my employees with wages as their sole compensation,
will do the wank,and the suuctum u nor intended or offered for sale(Sec.7044,Business
and Pm(essions Code:The Contractor's License law does not apply b an owner of Required Inspections
property who builds or improves thcrenn,end whod«aauchwo is himself or though his
own employ=,provided that such improvements an,not intended orofferedl Intricate.If.
however.Ne building or improvement is sold within one year of completion,the owner.
but]&'will have the burden of proving that be did not build or improve for purpose of
side.).
1,as owner of the property,am exclusively contracting wit licensed contractors to
construct one pmject(Sec.7(144.Business and Professions Code:)The Contractors Gi
nse law does cot pply o an owner of popeny who Nilds or improves Neuron,and
who contracts for such projects wife a contr mLor(q licensed pursuant to the CmUsmorrs
License law.
❑I am exempt under Sce. ,B&PC for this mason
.to Dat
WORKER'S COMPENSATION DECLARATION
1 hereby afro under penalty of perjury one of the following declarations:
1 ham and will maintain a CeniGeam of Cement o self-inche for Waimea Compcn-
sation,uprovided for by Section 7700 of the labor Code.for the perfenmance of the
work for which this rumnit is issued.
1 have and will maintain Worker's Compensation Insurance,aa required by Scculon
3900 of the labor Code for the performance of the work for which this permit is issued.
My Worke's Cnmpensatimn Insurance..(�artwic add Policy num
nare
Cartier. r s1-`1Pblscy�'a.: 5
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(ionseetimneed rothccomptemdifthe penchisimmehindmddollem($100)
or less.
I arufy that in the performance of the work for which this permit u issued,l shall not v
employ any person in any m ncr.so as in kcome subject to the Workcoi Compcnsauon
Laws of California.Dow
Applicant
NOTICE TO APPLICANT:If.after making this CeniOcam of Exemption.you should
become subject to the Worker's Compensation provisions of the Labor Code,you muff
JZ fmMwith comply with such provisions or this permit shall be deemed revoked. '
ZO
CON HUCTI ON LENDING AGENCY
[-.5 STI hemby affirm that dere is a construction lending agency for the Performance of
CL the work for which this permit is issued(Sec.3097,Civ.C.)
ALender's Name
=Z Lender's Address
U C 1 certify that 1 have Ind this application and sure Nn the above information is
F connect.I agree to comply with all city and county ordinances and some laws totaling to
O V building construction,and hereby amhone mpmsenatives or this city to enter upon um
r W above-mentioned property for molecules purpmes.
(We).,me in save,indemnify and keep humless the City of Cupertino against
rFi h liabilities.judgments.costs and expenses which may In any way scenic against said City
U in conmqucnce of the granting of this Permit.
APPLICANT UNDE`ROS2IT5A1NDS AND WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
CER Re-roofs
Signature of ApplicanVConlractor Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tM applicant tar forum building occupant more or handle hvudom mamriil ,
4m defined by the Cupenino Municipal Code.Chapter 9.12,and the Health and Sarety
Code.Semon 25532(x)? All roofs shall be inspected prior to an roofing material bei. Installed.
❑lire pNn P P Y g g
Will the applicant or future building occupant use equipment or dcvies which If a roof is installed without first obtaining an inspection,l agree to remove
emit hazardous air cmisco mss for defined by the Bay Arca Air Quality Management all new materials fOr mspectlon.
Discriet? /
C3 Yes QNu
1 have mad the harallous materials requirements under Chapter 6.95 or the Califm-
niaHealth&Safety Code.Sections 25515,25533 and 25574.1 undersand fire if the Wilding
does not cumensly have a meant,that it is my respomibility m nouly Nr.occupant of the
(f7�y lremcnka whichm t met pri eef.ceniocticAc upancy. Signature of Applicant Date
/' t'''" j,'�'Q� All roof coverings to be Class"B"or better
Owner r authorized agent Dam