04010042 (2) CI TY OF CUPERTINO *?'y r`
BUILDING DIVISION PERMIT �XQNTRACT,ORANFORMATION
BUILDING ADDRESS: _ CRW INDUSTRIES PERMIT No 04010042
ER'S NAME: PERMIT ISSUE DATE
NE: SANITARY NO. CONTROL NO.
(408) 32R-9,477
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
uoa LICENSED CONTRACTOR'S DECLARATION O O O O
YY wF 1 hereby affirm that 1 am licensed under provisions of chapter 9(commencing Job Description
SZ�y with Section](%%quf Division)of NC Rusirea.and Prpfc,A re Cm.edmylicenscis
i.1 fullforcederreee r�L�`Ly6J WINDOWS REPLACEMENT
ta of in i les Lie.
n F Dams T Cunlra
ARCHITECTS DECL ION
ft;a
1 understand my plans shall he used caput.e rccmd, F E e 1 p 2004
3 � Licensed Professional
a
aI OWNER-BUILDER DECLARATION
aV. 1 hereby alGrm that I am exempt from the Contractor's License Law for the r��lp ®'w�/'�
00 following reason.(Section 703 1.5,Business and Pmfessiuns Cmlc:Any city or county ktlVK L ��1L7k
K w ff which roommis a pcmtit to construct,almq improve,demdish,or repair any structure
°_y prior m its issumme.also require the applicant for such permit to file a,signed statement
< that heislicensed pursuanttothepmvislonsmnheCummcho'sLiecneclaw(Chaprr9 Sq.Ft. Floor Area Valuation
y-F� (commencing with Section 7")of Division 7 of the Busmeas and PreeeinnsCNe)ur
y 3$ Nom at he is exempt therefrand dm basis for the alleged exemption.Any vinlauon of
Settle.7031.5 by Ary Applicant far A permit subjects the applicant to A civil penalty of 3gl�jyi glgl�erpp Occupancy
not more man five hundred dollars(5500). P Y Type
1,a ownu of the pmpeny,m my employcu wire wage is their sole compensation,
will do the work.and tan sounum is not intended or offered for sale(Sec.7W,Business
and Professions Code:Thc Connor's Limenal law docs nut apply to an owner of Required Inspections
property,who builds or improves dtereon,and who does such work himself or through his
own employees,provided Phut such improvements ale not intended mothered forsale.If,
however,the building or improvement is sold within one yeat of complcdon,the owner-
builder will have the burden of proving mat he did Dol build or improve far purpn of
sale.).
1,a5 owner of the properly,am exclusively contracting with licensed contractors 10
construct Bre parapet(Sec.7(k44.Business and Pmrnsions Cade:)The Contractors Li.
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projcus with a contracou(s)handed pursuant to the Comeacloes
Latense Law.
I An exempt under Sec. .B&P C for this reason .
if Dam
WORKER'S COMPENSATION DECLARATION .
1 hereby affirm under penalty of perjury ore of the following declarations:
7-.,k
have and will maintain A Ccnif tate of Conant to self-insure for Worker's Compen-
n,a provided for by genion 1700 of dm Labor Code,for me performance of me
I
for which this permit is issued.
bave and will maintain Workefs Compensation Insurance.As requi¢tl by Section
of the Labor Code,for the perfarmancc of the work fur which this permit is issued.
Worker'�s.�C,oama�p�ensation Insurance carrier and Policy number arte rY,HTV r/vNO icyN.. IJr1/y '200•.3
CERTIFICATE OF EX&M Pr r OMWORKERS'
COMPENSATI NIN_SURANCE
(This section need not he completed if the Permit is for one hundred dollars IS 100)
Or lea)
I cenify,mal in the performance of the work four which this Permit is issued.I shall nut
employ any person in any manner At az At become subject to the Wortrri Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL aper making this Ceni Ream of Exem prion,you should
become subject 10 the worker's Compensation provisions of me Labor Cake,you most .
., forthwith comply with such provisions or this rami l shall he deemed revoked.
7-0 CONSTRUCTION LENDING AGENCY
Fw I hereby oMrm tan mere is A conswcbma lending agency far me performance or
a the work fur which this permit is issued(Sa.3097,Civ.C.)
D] Larder',Name
= z Lender's Add. _
U Q 1 certify Nat 1 have read this apIdic.fi n and nem that the above information is
Iy E-' concis.I Agree to comply with all city and county ordinances and Mute laws relating to
�U building construction,and hereby Authorizeopresentatives of thio airy to enter upon the
r 4 shove-mentioned property,for inspection purpose&
(we)agree to save,indemnify and keep harmless the City of Cuporino against
,Hr N Hatt lilies,judgments.costs and cxpumes which they in any way accrue against said City l
U Z in consequence or me granting of this permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WIT NON-POINT Issued by: Date
SOURC jRE CATIONS. �
Re-roofs
Stg um of Applicant/Comracmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applinnl or future building accurate mom or handle haaallous material
az def red by the Copeman Municipal Code.Chapter 9.12,and the Health and Safety
SccGon 25532(ar/ All roofs shall be inspected prior to any roofing material being Installed.❑YAM No
Will the Heart or future building t use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
pp g bedpan
emitharardnus air contaminants as defined by de Bay Arca Air Quality Management all new materials for inspection.
Disvin7
❑Yes
1 have read the hu arJous materials requirements under Chapter 6.95 of me Califor-
no.Health&Safety Code.Savuss 25505.25573 And 25534.1 undersand mat if dee building
does netcm mly ba tenant that it is my respmsibiloy w nodi the Occupant or Nc
tcquimmc mwnk station, dartoissuaneeoraCerdr amar dp Signature of Applicant Date
owner nnered agent i ate All roof coverings to be Class "B" or better