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04080070 CITY OF CUPERTINO nulLDrnc DIVISIoN PL,�RIVIIT NCONTRACTOR INFORMATION BUILDING ADDRESS: PERMIT N0. CRW INDUSTRIES 04080070 NTITV AIT OWNER'S NAME: PERMIT ISSUE DATE Apn Ir E: SANITARY OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLOC ELECT PLUMB MECH 0 0 0 0 urea LICENSED CONTRACT'OR'S DECLARATION x w C I hereby affirm that l am licensed under provisions or Chapter 9(commencing Job Description 1U. with$cella 7 Bar of tc Business fcssiolls Cadc,and my lnameacs in mora. r 4�u2 /gy WINDOW REPLACEMENT (7) On? Lianac Cl atone/O LicR ZF, lam Contractor CN-w /HO ='fou ARCHITECTS DEGLAR ION �i K 1 understand my plans shall be used v puM1B rtCrew is U B u01- ssinmal Licensed Profe g OWNER-BUILDER DECLARATION iP I hereby affirm tel 1 am exempt from lbe Contractor's License Law for the 00 following mason,(Section 7031.3.Business and Professions Code:Any City or county Km- which mgaises a permit to construct,soler,improve,demolish,or repair any structure au ,—O poor ha its issunace.also requires the applicant forsuch penniuo rile asignN summon Hjthat he is licensed Pursuant to the provisions of theContracm,suanaeLow(Chapter 9 Sq. FL Floor Area Valuation `z t-a (commencing wi in Section 7020)of Division 3 of the Business and Professions Code)or Of Out he is exempt thomf.m and de basis for the alleged exemption.My violation of Section 7031.5 by airy applicarn fon pemtit subjects the applicant to a civil penalty or 3 ASMA104er00 Occupancy Type not more tan five hundred dollars($500). r 1,as own.of the props ty,oa my employees with wages as ttls sole compensation, will do the work.and to mo clure is not intended mofB.d foss].(Sec.7064.Business and Pnywh ons builds pro esdom in.and Law docs sol apply ff an ownu of Required Inspections property who builds ar improves Lemon.and who Oyes such work himself offered his owneer.me uiprovided pr such improvements the not intended mmoBeretl for sale.If, builder thebuildingorden of proving Our said within one year or completion.to owe or builder will haus the burden of pmvin6 Nat he did nal Wild or improve for purpose of sale.). ❑I,as Owner of the property.am exclusively contracting with licensed co enscmrs to consumer the project(Sec04 70 ,Business and Prolusions Cade:)The Comvuiond most la c c wdoes not apply ban Owner of property who Wilds oaimproves thre eon,n,ad bo wcontacts for such pmXcts with a contnnor(s)licensed Dursuam m the Conuumts V/ Lice..ta 0 1 am exempt under Sec. .B At P C for this mason Owner Data Alm WORKER'S COMPENSATION DECLARATION 1 hereby of ins under penalty of perjury ore of to fallowing declarations: have and will in a Ccrufcatc of consent to self insure far worker's Cumpcm nation,u provided for by Section 37M of the tabor Code,for the performance of the work for which this p.it is issued. ❑I have and will maintain Workers Compensation Insurance,as requied by Section 37M of the LaWr Code,for the pcorcrmsne of to work for which this posit is issued. My Worker's Compensation Insurance carrier and Policy numWr am: Ca �e 5 f FVnfD ParayyNNpp: (oB7B -s2W3 . CERTIFICATE OF EXEMPTIOaYPSEOM WORKERS' COMPENSATION INSURANCE Glair section need not be completed if Ibe permit is fstronc hummed dollars($100) nr mss.] I eaatify that in tc performance of the work for which this permit is issued.1 shall not employ any p.vun in any manner inti to become subject o tW WorkersCompensation Laws of California.Dale Applicant NOTICE TO APPLICANT:If.arta making Nis Cenificam of Exemption.you should become subject to to Worker's Compensation provisions of the La Wr Code,you muse 2 forthwith amply with such provisions or this permit shall be deemed invoked. zCONSTRUC`DON LENDING AGENCY 'e. I hereby affirm that tem is a conswction lending agency for the perfurmane or oe the work for which this permit is isimd(Sec.3097.Civ,C.) W^n- Landers Name z Lcndcr's Address V O 1 certify tat 1 have read this application and sum that the shove information is LL F coney 1 agree to comply With all city and county ordinances and some laws relating b O V Wilding construction.and hereby suthorrn mineaenlaLlwa of thiscity menmr than.the a ahove-memianed p.perty for inspection purposes, ,r (Wit)agree to save,indemnify and keep harmless the City of Cupertino against N liabilities,judgments.costs and caperims which may in any way accrue against said City U Z in Whoetpemce or to grsoting or this permit. ^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date e6/�� OURC�EGULATIONS. B to J Re-roofs Dam Signamrc of Applican✓Contracur HDOUS MATERIADISCLOSURE Type of Roof Will II dm applint" or AZARLS ruure building occupant sem or handl.havaNaos ntamnal as do In by tc Cupertino Municipal Code,Chapter 9.12,and the Health and Safety Its e.Section 25532(x)? a All roofs shall be inspected prior to any roofing material being installed. ❑Yes Will 0Yme applicant as mwm Wining aaapant use equipment aadewmes which If a roof is installed without first obtaining an inspection,I agree to remove t haiaNnus air contaminants defined by tc Bay Arca Air Quality Management all new materials for inspection. uict? ❑Yes Nu I have sad the havaNnus materials requirements under Chapmr6.95 of the Calif., Health&SafetyCode,Sectio.255(15,25533 and 25534.1 mderaland thaliflhe Wilding s not currently have a moans.tat h is my mmunsihili y In notify dm occupant Of the uka which moot he mat pnm les iasaana or.cenirumor Ocapana. Signature of Applicant Date �19t,7 All roof coverings to be Class "B" or better r or amharized agent Dam C TY OF CU13F.RTINO - BUILDING DIVISION PERC�NTRA�TIR INFQ�MA�N BUILDING ADDRESS: PERMIT NO. CRW INDUSTRIES 04080070 OWNER'S NAME: PERMIT ISSUE DATE PTrPAPn F, NANrV MAK 1157 IDRT-T- AVE ONE: SANITARY 0 OL NO. ARCHITECf,ENGINCER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH O O Isnor, LICENSED CONTRACTOR'S DECLARATION 0o Job Detri o sU C I hcrcby affirm Nal 1 am lianxd under provisions of Chapter Y(commencing s IALW i UW witM1 Scaiop lry%1)of Sof llm Busincas fcssiunx Cotic.and my license is mmur C1 1 . mon ./u2 -42) WINDOW REPLACEMENT (7) Z�Z Li¢nsc Cl L l0 Conte =pus Dam U GrnDECL RFIC JAN ZS 2005 -t ARClIITELTS DEClJ.R ION �i lundcrsund my plans shall he usedaz puh0 rccnNs ��II{�''J�J/�/�{1,f/I'I 1'�'ttIII1����\\\\\If(1r11 3 LL Licensed Professional a0 OWNER-BUILDER DECLARATION Comr ON S I hereby affirm'he I am exempt son the Cssions o e:Any Law co the v,o which mtuoa.Permit t Rood Business improve ve dcares Code:Any city or county K m� which rtyuims a pcmnit m wrmrwt,alcor.improrc,dcmofhrh,m repair any strvnum m—'^ prior In its issuance.also requires the applicant for such permitto file a signed etvcment ssz'< that he is licensed purmantmme provisions ardor Conmacmrs License Law(Chapter 9 Sq.Ft. Floor Area Valuation as (commencing with Scction7000)rd Divisien3 ofihe Busincssand Prnfessinas Codc)m to 5 that he is nampt thcmfrom and the basis for the alleged exemption.Any violation of Section]031.5 by any applicant for a permit subjects the applicant to a civil penally of 30,SV ITt9L1per00 Occupancy Type t more Nan five hundred dollars($500). ❑1,as owner of the p tpcny,or my cmplryar s with wages as their.anle compensation, will do the work and the awaure is not intended or orrered for sale(Sec.7014,Business and Pmfusslras Code:The Cmucaetnrs List.Law does not apply In an owner or Required Inspections pmany who tourism improves thercon,and who does such work himxlrorNmagh his own employees,provided that such improvements are not intended or offered for sale If. however.the building or improvement is sold within one year or completion.she owner- builder will have the burden of proving that he did not build or improve for purpose of sale). ❑I, a owner of the propert,am eslusivcly conuaning with licensed crura to construct the pmjat(Sec.7W,Business and Professions Code:)The Conlnemr's Li crate Law docs not apply to an owner of propcny who Wilds or improves Wrier ,and. who contracts for such projects wish a smoractor(s)licensed pursuant o the Contractor's License lbw. O 1 sm exempt under Sec. .B&P C for this return Owner Date WORKER COMPENSATION DECLARATION I hereby affirm unhr penalty of perjury am of the following declarations: . ❑1 have and will maintain a Ccni0lram of COMCnI to self-insure for Workces Compca- union,as provided for by Section 37(1(1 of the labor Code,for the performance of the work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Bovies ner,n required by SrcOon 3]00 of she Labor Code,for the performance of the work for which this permit is issued. My Worker's Compensation Insurance carrier and Policy number am:- ��II Cal .if�I' NIP PoliayNg.: ecp6 —d-co3 CERTIFICATE OF E%EMPI'ION Pkc WORKERS' COMPENSATION INSURANCE (This action need not be complemd if the permit is forme hundmtl dollars(SIM) n less.) 1 certify that in the performance of the work for which this permit is issued.I shall not .. cr,5\toy any person in any manner an as to become subject to the Workers Compcnsadon Lava or Califomia.oam As.s;ica c NOTICE TO APPLICANT:If,after making this CcnlOcme of Excmptirn,you should ,ccome subject to the Worker'a Camp,matirn provisions of the Labor Cale,you mum �Z. rbMwith comply with such provisions or this perm it shall be deemed¢voted. - Z O CONSTRUCTION LENDING AGENCY P� I hereby affirm that Nene is a construction lending agency for the performance of C4 Ne work for which this tremor is issued(S..3097,Civ,C.) 4a Q Lcndcrs Name Uadcr's Address V CD I certify that I have read this application and scam that the above inf na miun is Ig, F" correct,)agree to comply with all city and county ordinances and state laws relating to 0O building construction,and hereby iuthmiae representatives or Nit city m enter upon dor r Uainspectionmcndonrd property for inspection purRraL (We)agree to save,indemnify and keep harmless the City of CuNnino against F" aj liabilities.judgments.costs and cepcnscs which may in any way seems again¢said City U z in UNDERSTANDS ANcrone granting of this D WILL COMPLY WITH ALL NON-POINT Issued by: Date ,SOURCE REGULATIONS. 64�� to A'E Re-roofs Signature of ApplicandCanuacmr Dam - HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will the applicant or future building occupant store or handle hazardous material az defined by the Cupenino Municipal Calc.Chapter 9.12.and she Health and Safety Code,Section 25532(x)? ` A+ All roofs shall be inspected prior to any roofing material being installed. Yes p Will the applicant or future building occupant use equipment rr devices which If a roof is installed without first obtaining an inspection,I agree to remove .mit hazardous air contaminants defined by the Bay Arca Air Quality Management all new materials for inspection. Disvia? ❑Yes Nu I have mad the harardous materials requirements under Chapter 695 of the Calirm- nia Health&SafeyColc,Sections 25505.25533 and 25534.1 understand We if 1M Wilding does nowurreally have a arrant,than it is my no,thasihility m nod l'y tan occupant of the Cyrimmcnts which mutt x met prior to i ouance oft Ccmficam of arrpanr. Signature of Applicant Date %�fo :012 All roof coverings to be Class "B" or better Ow r automizcd agent Data 0 NA E F r ge v N z g.0 77 C ems' re L 4 _-- _ l" p o Rix pa cr, 'Zp U Y � vymG3 2 w UEi I " m o G y rj _ z m $ g,� � y n24J � Eg mm - m _ OL £cr 0 AC w r1 A 5 m OCITY OF CUPERTIN09 C, � 0 ? o ,) '7 CITY OF PERMIT APPLICATION FORM CUPEkTINO PN # Date: S Ito /Zooy Building Address: Mailing Address (if different from building address): 10541 S. BtAn1Ey Owner's Name: Phone #: MAK 17,10JAA.D s K4KCY Contractor: License #: Cnw INDvSM(ES go2y8y Contact: Phonefti-t>4711. -b8zt. Cupertino Business License#: R000nr P-wn.Pu-f Fax:CLI-S_) 378 - 24O9 23525 Building Permit Info: Bldg ❑ Elect ❑ Plumb ❑ Mech ❑ Job Description: QEft.4LoAe-ar oG WIMDOws STf%%cr- Residential R1 t?LEva;1o./ s. t<iawem okv( ('I TbT4t-) Commercial ❑ Sq.Ft. Floor Area: $/Sq.Ft.: Cost of Project: Occupancy Grou Type of Construction: Please check As box i 'theipr6iect is a Ank W11400WIC (Waco ,StO„Jy, second-stor ad roject Size: Standard ❑ Laze ❑ Major ❑ Quantity Fee ID Fee Description Fee Group BAPPLOTHER Other Appliances MECHANICAL BBLDGFEE Bldg Permits . foot BUILDING BBOILERI Boiler<= 100,000 Btu MECHANICAL BBOILER2 Boiler> 100K to 500K Btu MECHANICAL BBOILER3 Boiler> 500K to 1M Btu MECHANICAL BBOILER4 Boiler> 1M to 1.75 M Btu MECHANICAL BBOILER5 Boiler> 1.75M Btu MECHANICAL BCONSTAX Construction Tax BUILDING BCONSTAX Ind/Off/Comm/Quasi BUILDING BCONSTAXBQ Con. Tax for BQ Zone BUILDING BCONSTAXH Hotel and Motel BUILDING BCONSTAXR Constax -Resi/Mobile BUILDING BELEC1000 Elec 600V <= 1000A ELECTRICAL BELEC1001 Elec 600V > 1000A ELECTRICAL BELEC200 Elec Svcs 600V <=200A ELECTRICAL BENERGY Energy BUILDING BENERGYADD Energy Add Multi BUILDING BINVESTIGA Investigation fee BUILDING .l6 6 1 of 3 D �ITY OF CUPERTINO� CITY OF PERMIT APPLICATION FORM CUPERTINO Quantity Fee ID Fee Description Fee Group BMISCELL Miscellaneous Fee BUILDING BMITIGATC Comm. Housing Mit. Fee BUILDING BNUCOMME New Comm Electric ELECTRICAL BNUCOMMM New Comm Mechanical MECHANICAL BNUCOMMP New Comm Plumb PLUMBING BOVERTWE Inspection Overtime BUILDING BPBACKFLOW Atmospheric Vacuum PLUMBING BPCESSPOOL Cesspool PLUMBING BPERMFEE Bldg Permit Fees BUILDING BPFIXTURE Pblg Fixture PLUMBING BPGAS Gas Piping System Fee PLUMBING BPINTERCEP Ind Waste Interceptor PLUMBING BPLANCHK Plan Check Fee BUILDING BPLANCKADD Plan Check Add Multi BUILDING BPLANCKREP Plan Check Repeat Fee BUILDING BPREPIPE Re i e Of Fixtures PLUMBING BPSEWAGE Sewage Disposal PLUMBING BPSEWER Sewers PLUMBING BPSPRINK Lawn S rinkler/Backflo PLUMBING BPSTORM Storm/Rain Water PLUMBING BPTRAP Kitchen Trap PLUMBING BPVENT Alt of Drain & Vent PLUMBING BPWATER Install/Alter Water Pie PLUMBING BPWHEATER Water Heater/Veut PLUMBING BPWSVCS Main Water Service PLUMBING BREINSPECT Reinspection Fee BUILDING BREMACOVER A/C Unit> 10,000 cfrn MECHANICAL BREMAIRHAN A/C Units <= 10,000 cfrn MECHANICAL BREMAPPLI Appliance Install MECHANICAL BREMBUSWAY Remodel Busways ELECTRICAL BREMFIXT Lighting Fixtures ELECTRICAL BRENUIRN Relocation of Furnace MECHANICAL BREMFURNOV Relo Furnace > 10K btu MECHANICAL BREMHEAT Heater Installation MECHANICAL BREMINHOOD Installation of Hood MECHANICAL BREMMISC Misc Apparatus ELECTRICAL BRENB-4 PP Rem Non-Res Appliance ELECTRICAL BREMPOLE Pole/Platform Fixture ELECTRICAL BREMPOWER Power Device/Apparatus ELECTRICAL BREMRECEPT Rc tl, Switch & Outlets ELECTRICAL BREMRELOCA Relocation of Hood MECHANICAL BREMREPALT I Repair/Alter Heating MECHANICAL 2 ora Se, `ITY OF CUPERTINO mYOF PERMIT APPLICATION FORM CUPE'�T. INO Quantity Fee ID Fee Description Fee Group BREMRESAPP Remodel Res Appliance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Remodel Sips, Marquee ELECTRICAL BREMTHEATR Theatrical Lighting Fix ELECTRICAL BREMVENFAN Vent Fan Single Duct MECHANICAL BREMVENSYS Ventilation Systems MECHANICAL BSCBLVD Scb Specific Plan BUILDING BSEISMICOM Seismic Commercial BUILDING BSEISMICRE Seismic Fee Res BUILDING ESPECIAL Special Inspection BUILDING , BSWIM Swimming Pool BUILDING BTEMP Temporary Power ELECTRICAL BTEMPPERM Temporary Bldg Permit BUILDING BTEMPSVCS Temp Dist Svcs ELECTRICAL BUSLIC Business License BUILDING ELECTRIC Electrical sq foot ELECTRICAL EPERMITFEE Elec Permit Issuance ELECTRICAL MPERMFEE Mechanicals . foot MECHANICAL MPERMITFEE Mech Permit Issuance MECHANICAL PPERMITFEE Plumbing Permit Issue PLUMBING PPLBG Plumbing Fee sq foot PLUMBING ZADDCHG Address Change BUILDING 1 3 of 3