04010042 (3) CITY OF CUPE2'PINO r—V "
BUILDING DIVISION � PRRMIT' g�p*�,(CONTRACTOR INPORMr,
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BUILDING ADDRESS: CRW INDUSTRIES PERMIT NO 04010042
21421 EID4 2-T
OWNER'S NAME: PERMIT ISSUE DATE
NE: SANITARY N0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
0
X00 LICENSED CONIBACfOR'S DECLARATION
w I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing lob Description
iE witM1$[cllOa]C(IU)U(DIvLdOnJ of me Busincs and Professions Code.and myliccnu is
in tiff r.e nd erRet Llt2g6d WINDOWS REPLACEMENT
j coi Li laf Lie.R C' ,
^o Dam ✓- TS DECE?� '
by i ARCHITECTS DECLA ION A
d I undcrsum my planssu l W used as,,m m reerod., )�
Eto U
T
at; Licensed Professional
jOS OWNER-BUILDER DECLARATION O/
1 hereby affirm that 1 am exempt from the Contractors License Law for the
p o following mason.(Stases](131.5, r.al ss and improve.
profession,Codc:Any city au county
K m which rets issu a permit r ennswn,alter,improve,b permit t or e a signed
igsoy student -
"�y tpror hat hni.isswnecraurt on
nthe lheappllcano roe mchpermiuocense Ignedsmoemem
< thmhciscing wJPSectio7")o(Disnns3 or the urines'and Professions
apter 9odc)Or Sq. FC Floor Area Valuate
xFE (commencing with Section l(100)of Division)or the Business and Profcssinns COde)m
a. ohm he u exempt Ihcmfram and the basis for me alleged exemption.Any violation of
Section 7031.5 by any applicant for a permil subjccut the applicant to a civil penalty of 3gv�j)i jQyrlt�er00 Occupancy Type
,not more than Eve hundred dollars(SSW).
1,az owner of the propcny,or my employees with wages is their mole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044.Business
and Professions Cod.:The Contractor's License Law docs not apply to an owner of Required Inspections
progeny who builds or improves thcrcon,and who doessuch work himself orthrough his
own employees,provided that such improvements are not imrnded oronered rot sale.If.
however.the building or improvement is sold within One Icer of completion.Ne owner
builder will have the burden of proving that he did not Wild or improve for purpose,of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contactors to
coram ct the project(Sec.704P4,Business and Professions Codc:)The Conlrscmr's Li
ern¢Law does not apply to an Owner of propenY who Wilds or improve mereon,and
who contacts for such projeeu with a contactor(s)licensed pursuant to B¢Conuactor's
Lacs.law,
❑l sm exempt under Sec ,B&P Cfir lhi.oaxon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 Mw and will maintain a Ccnificam of Cmuem oo self-insure for Worker's Cumpcm
Pup,as provided for by Section 3100 of the ISWr Code,for me performance of the
work for which this permit is issued.
❑1 have and will maintain Wmker's Compensation Insurance,ses required by Section
3700 of thc labor Costs,for Bac purformantt of the work for which Nis pcomil is issued
M Workers Compensation Inxumhrce camicI and Policy number am:
CERTIFICATE OF EXBMUWFROM WORKERS'
COMPENSATION INSURANCE
CIL'a seelion need not hecomplcoed irtha permit is forouc hundred dollars(1100)
n less)
I every moat in the performance of me work for which this permit u issued,I shall not
employ any person in any manner an sa to Wmme subject to the Workers Compensation
Laws of California.Date
Applicant
NOTICETO APPLICANT:IL artcr making this Cenificau of Exemption,you should
become Subject to the Workers Compensation provisions Of the Labor Cole.you mum
.J2 f.nhwith comply with such provisions or this Permit shall W deemed mwkcd.
Z O CONSPRUCr10N LENDING AGENCY
F" I hcmhy alarm But Bum is a construction lending agency for the Performance of
0.S 7 Ne work for which this .if is issued(Sce.3097,Civ.C.)
W Q Under'.Name
,z Lender's Address
V 0 1 eenify that 1 have rad this application and sate that Ne,a W ve information is
V, correct.l agree to comply with all city and county ordinances and slate laws relating to
0 V building conmmcoien.and hereby aomtriw represenaoives Of Nis city to enter upon he a
W shove-mcnioned property for inspection purposes.
U Z (We,)agree h saran Indemnify and keep harmless the City of Cupertino against'
fq Imbilitie,Judgmcnu.Co..and cs pons.,which may in any way accrue against said City
C)2 in APPLICANT
ofthegrand ngser this permit.
^ APPLICANT UfLIANDS AND WILL COMPLY WITH NON-POINT Issued by: Dale
SOURCE RE UI,ATIONATIONS.
Re-roofs
Srgsere oHAZARDOUS
f APPLcaRU' Date
HA7ZARDODDU S MATE RIALSDIgCLOSURE Type of Roof
Will the applicant or future buildinge.Chapter R12.andhanb Healthy material
u defined by the Cupertino Municipal Codc.Chapter 9.12.and IW Health and Satiny ,
Code Sanies zss3z(a)1 All roofs shall be inspected prior to an roofing material being installed.
' ❑Ye,, �Nn P P Y g g
Will the applicant or future Wilding acenpont use.wipmcut nr dunces which 'If a roof is installed without first obtaining an inspection, I agree to remove
all haiardnus air owanonan.az dcGn.J by th.Bay Area Air Quality Managcmeno all new materials for inspection.
stria?
❑Yes Nu
I have read ohc harardnusmamrials rcyuimmen.under Chapter 6:15 of me Calif w.
pia Health&Sony Codc,Sccuur15505,25533and25534.1 undcrsyW mhmifmM Wilding -
does not currendy he, mwnl,IS itis my responsibilitY ton natily mho hwcupant of Nc
rcgmr.meo b-1, 6ofl,.metpoortoiazu�oficaminr cep Signature of Applicant Date
Owner voborivedagent W, All roof coverings to be Class"B" or better
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