06050123 CITY OF'CUPERTINO *•^2ns�� `" +%� �xpaan "i° `
BUILDING DIVISION
PERMIT S��CUk�T.I!2.A.b R ioI� 4}ItMATT N�-
'r v'.: 3• ^n^r" x§aa4,r>,
BUILDING ADDRESS: OWENS CORNING PERMITNO.OFy050123
2 40 CRICKET HILL ED
O NEWS NAME: PERMIT ISSUE DATE
TAKAHASHI 3037 I
E: SANITARY NO. CONTROL NO,
925) 245-5238
ARCHn EC tENGiNEER: BUILDING PERMIT INFO
BLDG ELECT IS I� PUMBS MECH
O t�
3asp LICENSED CONTRACTORS DECLARATION Job Description
IU 1 hmby affirm Nat 1 un Ikcnsed under provisions of ChaP er 9(mmmecing
mitb Sectim T0110)af Dividon3ofde Budcuand Profeaiom Code andmylkcamh
+� Inrullroreeandeifm g�p '� NON STRUCTURAL KITCHEN REMODEL
)nk. DECLARATION Licenm Cl - Lk.B
I
W Dam Com
ARCHITECTS DECLARATION
1 I underworld my pins mall he used u public records
yy
;8C;
yd Lccmd Professional
OWNER-BUILDER DECLARATION
C<1O 1 hmaffirm atI ma exempt foam the Camuncto
rI lleanse Law for the
po following mason.(Section IIs IS,Business and Promubss Cade:Any city or manly
S$rwhich requires•pewit re contract.pier.Improv,demolish.of a sig any twelve $22000 n
z�^ outpriorheiuiawtdc,,oarol to otic aPions Of forsucthe Co men's Rleanigcdmmmem
�< (Comme licensed Sectiol ache of Division
ivisioof Ne CanaeceALlmnmLaw(Chapter odc)or Sq.Ft. Floor Area Valuation
$ (eat he Is exempt
it basis n3 of theBusinesspd ProfMyvi Cade)or
.• Nu h b avmpt memfran and Ue baso for the alleged eampdm.MY NaWlon of '
Section 7031.5 by arty aPPlimat for.permit subjects the applicant as a civil penalty of r Occupancy Type
not mom than ftwa hundred dollars(SSW),
❑1,as owner of the property,or my employees with wages as their ale compensation,
win do tha wart and the swmw is ant intended or offend farale(Sm.1044,Business Tred Inspections
and Proposal Cadm re
a:The Conuacmes Licenm Law does apply e an owner of P
property who builds orimproms tisammo,and whodoessuchworkltiwelfor through his
own emplaym,provided tlutauch improsemmu amnot intended moffetd for ole.If. ^
however.the building or improvement is sold within one year efmmpldan.the owner- / f
builder will haveNe an
have burdof proving dead he did anpurpose Wild improve for puoof 7
ale1, /
❑1,u water of the property,,B exclusively and contracting with )TheeCmnaalma m �/
construct des act(Sec.o an Business and property
who ss Cade:)Th Contractor's U.
who few doe not apply c an with
a of spuds who wilds or wproves merman,and, y�
who contracts for each pnkcu withaeonmacmrtU licensed purmantelh Conuaeh �//
Llecna Law. b
Alun eemptunder See .BkPC sur Nis moan
er Dao
WORKERS COMPENSATION DECLARATION
I sandy aRmo under penally of perjury,arc of ft Inflaming dmlannome
❑1 ham and win msnuin aCerdaate of Conant to self•Iusure for Workers Compet,
atian,u provided for by Section 3700 of the Labor Cade,fm de pesara nce of de
work for which Nil pewit is honed.
❑1 have and will msinuin Workers Compensation Insurance,as nquimd by Section
3700 of that labor Code,fm me performance of the work for which this pewit is Issued.
My Workers Compal alion Issuance carrier and Policy number are:
Carder. mil R/DWI L Policy No.:AWL(91��0T7
C GATE OF IXEMPnON PROM WORKERS'
COMPENSATION INSURANCE
a
(This mNan ted Out an completed time pewit Is fm me hundred doRan($1011)
or less)
I cmdly that In the performance of the wart for which this pewit is issued I Ns1 not
employ any permit in any sooner an as in became subject an me Workers'Compensation
laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in the Workers Compensation provisions of the lair Code,you nun
.,Zforthwith comply with such provision or No pewit shall be deemed o vokcd
Z O ray. CONSTRUCTION LENDING AGENCY
[a 1benby.M.Nat Nem bre consauctinn lending agency for me lerfawana of
C> dm wort for which wapermit I,issued(Sm.3WT,Co.C.)
W G Landers Nand
lander,Addrea
V O 1 certify that I Mw read this application and mm that me above In(owuion b
Iy coram I agree to comely with all city and county ordinances and sore Taws relating to
O V building conduction,and herebysuthadn npressmadvmof No city to courupna Ne
W ah.--ncmi acd properly for inspection pugmms.
(We)agree to saw,indemnify ad keep harmless Ne City of Cupertino against
liabilities.judgments.cmts and apmae,which may in any way scene.&asst said city
V in consequence of the granting of this Pewit.
APPLICANT NDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date -•+- l fs
SOUR UTA7�WNS.
Agm,&' Jyr/G�O�i Re-roofs C7 �Z--
Signature ofAppImmVConw o Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant or future building ouvpam sem or handle haaNao m,mrial
U deMd by the Cupertino Mantel Cade,Chapmr 9.13,and the Health and Safety
.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
[3yes No
will the applicant or mere wilding Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emh hoardnus sr cmumounu u defined by Ne Bay Atex Ar Cosily Management all new materials for inspection.
District? nYa_r/
❑Ye
Itsave read Ne havardtm mamdals mquinmenu undcr@upmr G95 arde Csifa-
saH.I"SauyCode,Sccdw25505.25533 and 25534.1 mhamnd mnirNc building
does oat CYwnlly have a mast,NmIt b my lefpOndblilty a nada,the meapant of the
reymire ole munhyy d miaummeancmdrtemar Signature of Applicant Date
All roof coverings to be Class "B"or better
Ower or authorirad ogee Oam' '