04060163 CITY OF CUPERTINO ° "�'� ".
BUILDING DIVISION PERMIT hr 0NTRACTORi4N�'rUTtMATTON
BUILDING ADDRESS: CRW INDUSTRIES P"`HTNO04060163
10701 S BLANEY AV
NER'S NAME: PERMITISSUE DATE
MADHU RAYABHARI 1157 DELL AVE , 06/18/2004
qE; SANITARY NO. CONTROL NO.
(408) 378-2477
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p o = C= o
+lop LICENSED CONTRACTOR'S DECLARATION -
z 1 hereby^form that I am licensed under previsions or Chapter 9(commencing IOb Description
n� with Socotra )of DMAm.3 ofte Busi*and ProfessionsCade.md my license is
pp inrallrM
Rem. REPLACE
REPLACE WINDOWS & PATIO DOOR
z y Z Licen�-16 Lk.N d ��
n r Dow GomDB5
,e ARCHITECT' .TION
y I undera�r�.My plan atsll M urea public reeantl.
7
30r Licensed Professional
I OWNER-BUILDER DECLARATION
^
i�E 1 herchy.lion that 1 Am exempt from the Conuocto,s License Law for the
i o o following reason.(Section TIO 1.5,Business and Professions Code:Any city or county
a�$ which acquires a Permit to construct,a@a improv,demolish,or repair any stractum
prior m its Issuance.also requires the applicant fofsuch permit to rile a signed moment
tZ< that he is licensed pursuant to provisimu of the Contractor's license Law chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section Hl00)of Division 3 of the Business and Professions Crew)or
$ that M Is exempt therefmm and the basic for loan allegod exempllm^.My violation of
Sectio.7031.5 by arty.pplicaat for A Permit acbitcu the Applicant M..MI pc..try or .3§0104binbero 0 Occupancy Type
Out marc Nan rim hundred dollen(MOO).
❑L e Menu of the dupery,merry intended
era wgu M Heir sole compenuaon,
will da the wmkrima,Cade: wuctuobmes Lictrum Law du formic
apply so a nc' Required Inspections
And ProfClUan3 Code:Tne COnraelara LNCNe LAW dM]oat apply f An owner of 1`. q p
property who builds^rimpmws tharcon,And who doessuch work himacllartNonth hw Y
own employees.Provided that such ImPmwmanuare not imman, anaRerW far uta IL
however,Ne building or improvement i.sold within one ye.r of completion,Me owmr-
builder w H have Ile burden of dmving Nu M did not build or impmw far pupwe of
sole.).
❑1.As owner of the Inaptly,am exclusively contracting with licensed rontractor,to
construct the project(Sec.70aa,Business And Professthm Caae:)The Com mares Li-
cause law does not apply to An owner of property who Wilds or improv themon.and
who conceals for such prejccu with acontrecta O)licensed Panama w the Conuacto,.
License law,
1 Am exempt under Sec. .B&P C for this mown %
Dow
WORKER'S COMPENSATION DECLARATION
I herchym.under Penalty of perjury am Mf ate following declarations:
aAwend will mainWna CenlBeawofComent m elf-inure fan Worke,sCompen-
1,r
n,u provided for by Section 37W of ace Labor Code.for the Performance of Me
for which Nis Permit is issued.
haw end will maintain Weakeri Compensation Insurance.As required by Section
of Ne labor Code,for Me performance Mfkn,want for which Mia permit is issued.
Worker,Compeesalion Insurance carrierand policy number art:
er, f�� Poll WORKERS CERTIFICATMPENSA M FROM WORKERS'
COMPENSATION INSURANCE
(This section need notbecmmpleua time lermh Is foram hundreddollm($10)
nr Mss.)
1 certify Met In Me performance of the work far which this permit is Wood.l shall not y
employ any parson in my manner an As In became subject to the W^rkeri Compensation .
Laws of California.Dew
Applicant
NOTICE TO APPLICANT:If,after making this Cenincaw of Exemption,you should
become subject ro the Worker's Compemation provisions of the Labor Code,you most
.J O forthwith comely with such provia..Or this permit shell w deemed reeked.
z ti CONSMUCfION LENDING AGENCY
F+ work for
whafRrm that them is•ed(Sm.3W7..Co. Agency for the perfurmancc of
C Meworktersonicthlapermul:issma(s«.3097.civ.c.)
aG lead^,.Name
Z)z endereMaacss
V Q 1 cenlfy that I how read this application And.uw that f^Wan information is
FfomCCL L Agree to comply with all city and county omi^wces and slaw laws totaling to
0 U Wilding construction,and hereby Authorim repma mitiwa of this city to enter upon Me
FT] abovmmcmioned property for inspection purports.
F 0. (We)Agree w row,indemnify and keep numtan the City of Cupertino against
IS �&0
y Ihbilitietjudgmenu,casts and expenses which may in soy wry amen against sad City
on'L)z APPLIC ueNT UNthe RSTungDftn ND WILL COMPLY WI NON-POINT Issued by: Date
SOU C REGU
'+'B� Re-roofs
S um of ApplicemurContractor Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
MI]the applicant or future building^ccuport store or handle hammons material
u armed by the Cupertino Municipal Code,Chapter 9.13,and the Health sod Safety
Section 25533(.)? All roofs shall be inspected prior to any roofing material b ing installed.
Y. "�Nu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hazardous air contaminants u defined by the Bay Area Air Quality Management all new materials for Inspection.
WICK
❑Yes S'N.
1 hew read the human.materials requitoments under Chapter&95ofthe Caiifor.
nit Haehh amlyCoM.Scctimu25505.25533ud2553a.1..l randlhatiftW Wilding
dors tcu 0' ate Ma his my rmlxxmi HUY to nary au mupn,of Me
re to n whi mus rmismanmofa ricewofoccupam.�y. '( Signature of Applicant Date
ow or.uthanrcaegenl Dam All roof coverings to be Class"B"or better