05030127BUILDING DIVISION PERMIT
(BUILDING ADDRESS: I OWENS CORNING IPERMITN5.5030127
ARCHITEC IEISGINEER:
Loo LICENSED CONTRACTOR'S DECLARATION
II hereby affmn that 1 am licensed under provisions of Chapter 9 reminiscing
with Section 70110) of Division 3 of the Businvs and professions Code, and my license is
I -
a full forand offs
Sg?License Cl U..a
i Date Comma— AWV A1751
ARCHITECTS DECLA
1 undenund my plana shall he used as public mc.,us
3 sari Licensed Prefessiavl
5 OWNER -BUILDER DECLARATION
I hereby . (Sect that 11. exempt from the Contacts o License Law for The
i O O following mason. (eclat 71131.(4 Business and Profdemoli Code Any city or county
v$ which roqufrtsa ,also to eonstrva,alar,Improve,h permit ore a siganyswment
F Z < prim m its f ensed P ..req. the thovisio s of the
Pennr's Ne a Law (stammers
Chat (commencing
rased punumt 70M of Division
of lM ConlrumitLavclaw(CNplm9
$ that M I.cin{withhectlan7and of Divisian3 of theBusinessesaand
on. Any
Cade) or
out he I. axcmpr therefrom and the bub it due subjects
t esemptia. AnY violauon of
Seton 1031.3 by any red dont lw • Permit suis%eta the applicant u a civil Penalty of
not more Nen Ove hundred dollars nsm>.
❑ I, is owner of ere property, a my employees with w{ea is Iheb role compensation.
will do Be wort, and Ne structure isnot founded "offend for sok (See. 7044, Busirsom
and Profemov Code: The Convcmrs License law dors an, apply to an ouster of
propertywho buildsorimpmv Btercon, andwhodouauchwork himrr3far through his
ownemploye:s, provided that such Improvements ate amt finendmi warranty for W. B,
however. the building or improvement Is mid within one year of cmnpletion, the owner.
builder will Mve the burdco of proving that he did set build or improve for purpose of
1, as owner of the property am exclusively contracting with licensed contmcmm m
awes the pm%et (Sec. 7044, Business and Professions Code:) Tie Conuaemrs Li.
m Law dost not pply to an owner of property who builds or improv Banks, and
who contracts for such projects with a conoxctor(0 licensed pursuant to the Contractors
License Law.
1 am exempt under Sec.
B & P C fm this rtsaon
Date
WORKER'S COMPENSATION DECLARATION
I hereby affiv under Penalty of perjury one of the following declarations:
wend aefll maintain aCetRam ofCovem Co self-inmm for WorkersComPen-
u provided for by Section 37M of the (-slam Code, for the p rfumme ie of due
Worker's Comperuadon Insurance, u required by Seton
IM performance of the work for which this permit Is house.
Insurance carrier and Policy number art:
section mod set W completed if Bre permit is for one hundred dollars (3100)
In Ne Performance of Bm work for which this Permit is issued. I Nall
employ any person in any manner in as m become subject to Hsu WorkersCompensation
Laws of Celifomia. Data
Applicant
NOTICE TO APPLICANT: If. after making this Cenillcam of Exemption, you should
bocame subject to the Worker's Compensation provisions of the Labor Code, you most
.JO forthwith comply with rush provisions or this permit shall bo domed revoked.
z CONSTRUCTION LENDING AGENCY
E.v ry.I hereby a1Drm that there is a constwelinn lending agency for the Performance of
FL � the work for which this permit Is Issued (Sec. 3097. Civ. C.)
0.W Gi Lenders Name
Lends',Addrom
U Q I anify that I have mad this application and sum dust The above information is
Iy F coned. I agree to comply with W city and county ordinances and sum laws misting to
QU building construction, and hereby aushodre representatives of this city m enter upon the
Ili shovnmenihmed property for impaction purpoxa
LL (We) agme to save, indemnify and keep harmkst the City of Cupertino against
rA Ifabilites,judgments, costs and expenses which may In my way arm against said City
U Z in consequence of due {ranting of Nis PemyIv
m-+ APPLICANT UNDERsT&NDS ANDiR'Iy.L COMPLY WITH ALL N041 -POINT
HAZARDOUS MATERIALS DISCLOSURE v
Will Bre apptiesnt or future building occupant ante a handle hazardous materia)
as defined by Ute Cupen rut Municipal Code. Chapter 9. 12, and the Hesith and Safety
Section 15531(.)7
Yes
Will Hee applicant o alum building occupant use egWpmenl or devices which
I harardnm air contaminants as defined by The Bay Ama Air Quality Management
Oinficl7
❑Yea p�f�
1 have setshe hmaNtat,ro mialsmqufmments underCMpmr6.95 ofHm Caliror.
me Hoalth& Sefsy Cade, Sectiav 25A15,15573 arW25534.1 untleuusW ButifNe building
docs not curmnlJy,�ow m atJ{ is my nesponsihiliey m ratify, Hsu occupant of due
myuiryp IyeseCr 'fiNc m bmal ppymimumaofa CcnilkamofOccuom"..,
FlU(MIrI Uld UKM
Job Description
BATH REMODEL/RECONFIGURE DIVIDING
NON-BEARING WALL
32603051.00
Issued by:
Re -roofs
Type of Roof
TUN 660
Date
CONTROL NO.
M •
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class 'B" or better