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CITY OF CUPERTINO
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BUILDING DIVISION PERIVIIT
"TIION
BUILDING ADDRESS:
CRW INDUSTRIES
PERMTr No' 06120005
10810 WILLOWBROOK WY
OWNER'S NAME:
PERMIT ISSUE DATE
NAKAGAWA TAD
1157 DELL AVE.
12/04/2006
NE:
SANITARY NO. CONTROL NO.
(408)378-2477
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm than 1 ma licensed undar provisions of Chapter 9 (mmmaming
Socf�Division3afNcBmdncssandProfessionsCrNe.ammylicenuu
inulareande
REPLACE 2 PATIO DOORS AND 2 WINDOWS LIKE FOR LI
ae°,aclu' Lk.N
Dau Contractor1
D
WINDOW BRINGING UP TO CODE
ARCHITECTS DECLARATION
1 understand my plans shall W used as public .,.,a
Lianud Pmfessiorod
OWNER -BUILDER DECLARATION
I Wmhy affirm that I am exempt from de Contractor', Ucenu Law for the
following mss... (Sean.. 701.5. Business and Prefessi.m Code: Any city fir entry
.
which requires a Permit to cmnevua, alar, improve, demolish, or repair any structure,
! prior to its smans, also acquires me applicant for such permit to rile a signed statement
that M is licensed pumemn to the provisions of the Contrxcter', Uncom Law (Clnpm 9
Sq, Ft. Floor Area
Valuati$r6 0 0 0
(commencing with Section 7000) of Division 3 of the Business and Pmfeuiots Codc)or
I mat he Is exempt therefrom and the basis for me alleged eaemp ion. Any violation of
APN Number
Occupancy Type
Section 7031.5 by airy applicants for a permit mbj.m tate applicmu. a civil penalty of
an, mom man ewe hundred mllam (shoo).
36922046.00
with wags u me'v sok compensation,
❑ Las owner ef,he pmpmsen m myn,
Required Inspections
uncraw ed use,(see70 aa, Btna..om
will eothcwmk, and bundled
iens does of
Thecomismes License
and Professions Cade: The Cmt mr's Liv she Law dors apply lf ,t owner
q p
h work h gaffe ser through his
at al is
property who builds vi improsv thereon, and who a
Own employees, providedmatinch imProe nota tar sale B,
ear
ofdmaRmea
id wuntienos
the owrcr-
. me building or Impmamms u sola within ore year of aurnaf
r
builderwill ease the burden of proving that he die not build m impreve far purpose of
Witec,
sale.).
❑ h as miner of the property, am exclusively contracting with licensed canufmars to
construct the project (Sec. 70M, Business and Protestations Cade:) The Commodes B-
eane Law docs not apply to an owner of property, who Wilds or improve thereon, and
who co unums fm such p.Xm with a continuants) licensed purmam to the Contractors
License Law.
❑lam tun r _ .B A, PI�1C f/gqqq//rdos1�cam.
Owrcr Dam 44,
W RKER'S COME ATIO DECLARATION
1 hcmby aRm under petWty, of perjury One of to following dclarmains:
Ihti a ad will maintain a CertificaeofC.W.ttoselfinsure for Worker'sCareful.
satian. as provided far by Samoan 3910 of the Labor Code, for the perform.. of the
works for which this permit is issued.
0 1 have and will maintain Workers Compensation Insurance, as nryuired by Secfion
37W of the Ube, Cattle. forth. pmformanecoftle work, for which this pemit is issued
'
My Warkees Compensation Insurance carrier and Policy number are:
Cartier. Policy No.: _
CERTIFICATE OF EXEMPTION FROM W=ERS'
COMPENSATION INSURANCE
(frits section mad not hec.mpledd if Lou Permit is foranc hundred dollars (51W)
or cia.)
1 certify that in the Performance of Ne work for which this permit is timed. I shall net
cmpa permuin inlany m r.wpgd heWst,e subject to me Worke,i Compensation
Law s of :a' a, w•yn,y�tsvk"•! 3%10
OfCa
Applicant
NOTICE U NT: IL after m#jng this Certificate of Eacmption, you should
baame ser t In the Workers Compensation provisions of 0e Labor Code, you most
' forthwith comply with such provisions Or this pemit shall he decmM revoked.
j CONSTRUCTION LENDING AGENCY
I hereby alBm that there is a construction lending agency for the Performance of
'
' the work for which this permit is issued (Sec. 3097, Civ, C)
Lenders Name
Landees Address
'
I anify that 1 hale mad this application and more that the aboss in[ omatiun is
' correct. 1 agree to Comply with all city and county ordinances and aum laws mlating to
Wilding construction, and hemby authmrlm representatives of this city to enter upon (be
alvvemcn.diplns.property for inspccuan
r puposm
(We) agree to save, indemnify and keep hamles the City of Cupertino against
i ti which ms
ImbiRi swhich they in any way accuse agaimm said City
musaea,judgmenu,c.ssang Of this
A cPLICANT ofthepantingof Nh pcmit.
' APPLICANT UNDERZr4kNDS D WILL COMPLY WITH ALL ON -POINT
Issued by: Date
SOURUL N
(
Re-roofs
Signa m fApplicantCorractor p
HAZARDOUS M RIALS DISCLOSURE
Type of Roof
Will the applicant Or future Wilding.ccupms store at handle hararcom material
as defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Code, Section 35532(.)?
❑Yam �Na
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future Wilding Occupant use equipment or dcvias which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hannous air conuminers as defined by Ne Bay Area Air Quality Management
all new materials for inspection.
District?
. 0Yu
I have mad dm WraNwTTs m�\aurias; rcquircmenu under Chapter 6.95 of the Califm.
s
nu HcalthhSofciyCode,Satiw35505,35533am135534.ImutrvmethaifNc Wilding
does not momently ham a unapt at it es my responsibility to notify tan occupmt of to
re4uircf cmurlmcc& `e"P`rfy ISignature
of Applicant Date
(
All roof coverings to be Class "B" or better
Owner. merit) -d cd agent
am