02120034 CITY OF CUPEWI'INO .
BUILDING DIVISION PERMIT "CONTRACTOR INFORMATION.,:»`
Bre B @PEsuTEVENS CREEK BLVD PERM]rN02120034
U10c MONARCH APPLICATI!)NlSI/IYIY@'N 2 O O2
PHONE: SANITARY NO.// ��//���� CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MELD
0 0 0 0
000 LICENSED CONTRACTOR'S DECLARATION Job Description
�n I hereby Off.Net I am licensed anile,pmvisiom of Coupler 9(commmming NEW SIGN P
with Section711fa1)of Division3of the BmineasanJ Professinm Gak.enJ mylicense is
� „ inmBfnmeanderree '1 75�1d(o3 CONTRACTOR: SIGNS OF CALIFORNIA
GZta4 License Class ryyl Lica
Dale Conmmor
rg ARCHITECT'S DECLARATION
a� I understand my plans soul)M..ties public records
� Licensed Profeatimad
y OWNER-BUILDER DECLARATION
8 fI hereby from that 1 am exempt from the Cmuracmr's License Law for the
_Q O following reason.(Section 7031.5.Business and Professinns Code:Any city or county
w3 iii which requires a Permit m construct.akc improve.demolish,or repair any structure $2400
FiP}+ prior to its issuance,also requires the applicant for such Permian file a signed sediment
x< Nat he is licensed pursuanuobeprovisions ofthe ContractoreLicense Law(Chapter9 Sq. Ft. Floor Area Valuation
WWSF (commencing with Secti.n l(lll(1)of Division 3 of the Business and Professions Conklin
Nat k u exempt therefrom andthe basis for the alleged exemption.Any violation of 35908020 . 00
Section 7031.5 by any applicant for a permit subjects the,applicant to a civil Penalty of APN Number Occupancy e
not more than rwc hundred delta.(S500). 101 — FOUNDATION P Y1YP
❑I,as most of Ne property,or my employees with wages m their sole compensation,
will do the work,and the strucwre isnot intended.,offered forstle(Sec.7044,Business
and Professions Code:The Conmcmfs License Law does not apply m an owner of104 - REBAR Required Inspections
property who builds or improves Nemon,and who does such work hima df or through his
own employees,provided Natsuch improvements arc not intended or offered for sale.If, 105 — ANCHOR BOLTS
however,the building or improvement is sold within one year of completion,be owner.
builder will have the burden of proving Nn purpose he did not Wild or improve for puose of 304 - ROUGH ELECTRICAL
aide). 505 - FINAL ELECTRICAL
C]1,m owner of the property.em exclusively conning with licensed contractors to 514 - FINAL P BLIC WORKS
construct the project(Sec.]044,Bminess and Professions Code:)The Contractors Lt
cense law does not apply to an owner of property who builds or improves Merton,and
who cts for such projects with a comactor(s)licensed pursuant m NC Contractor's
Yrealaw.
em rept under Sec. .B @ P C f Ni tion 7 �
al SAT N D t ,�
KE ON',
I herebya1Rnn under penalty of perjury one of the
Ifollowing dcelmNons: �
F-✓
❑Ihaw and will morby ation37amofCc u0sill-inam for Nbrtans Comrenl
workf r provided for mi Section 37IX1 of Ne lakr Code,fn,Ne plrionnancc of lbk
work for which this permit is issued. tvI Z,. U
❑I have and will maintain Worker's Compensation Insurance,is required by Section
3700 of to Labm Code,far the peRormance of the work for which this Permit is issued.
My Worker's Compensation Insuance carrier and Polity number am:
4 Policy No.:
CERTIFICATE OF EXEMPTION FR ORKERS'
COMPENSATION INS »NCE
(This section need not k completed If the Permit is formic hundred dollars($lap
me less.)
1 cenify Net in th performance of the, apeka f, hich this Permit is issued,10.51 not
empI
oy any many moon, m Z eSuhimv talk Workers'Campenmtion
Laws of lifer a. c �/ -L�
APP c
N TO A LICA .If,a maks gthis Corprovisions
of LaborC Code.
ushould
st
m m the W. Compensation Previsions of be Labor CnJc,you must
OO forthwith comply with such provisions or this Permit shall be deemed revoked.
z CONSTRUCTION LENDING AGENCY
[-+ �Nw I hereby affirm Nat there is a construction lending agency for the performance of
(Y,z the work for which this Permit is issued(Sec.31Y97,Civ.CJ V
14
Q Lenders Namc
�z Lender's Address
U Q 1 certify that 1 have read this application and state Nn Ik show informanon is
a F correct.I agree to comply with all city and county ordinances and man laws relating to
O U building construction,and hereby authorim representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
(Wo)agree N save,indemnify and keep harm loss the City.f Cupertino against
raj) liabilities,judgments,costs and expenses which may in any way accrue against said City 1
U z In consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALLNO 0 NT' Issued by: Date
SOU REGO A ION . Q� /N � Q
--Re-roofs
¢lure of phcaH omData rucmr ATERIALS DISCLOSURE Type of Roof
Will dam applicant.,fnturc bmf c pen tamre or handle hrallous anate69
derined by be Cupertino Muni Code,Chnp.1s',
r 9.11,and the Health and Safety
e.Scmthn 25531un All roofs shall be inspected prior to an roofing material beim installed.
❑Yea N. P P Y g g
Will the aPplicam r funtrc Dui 6 occupant use equipment ser Jcviccs which If a roof is installed without first obtaining an inspection,I agree to remove
emit haaardous air commmimnts efnod by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes No
I have mad the hasardous materials requirements under Chapterli.95 of the Califor.
mu Health@ Surety Code,Saint onv255o5,25533 mJ 15534.1 understand thatif de building
;EO�'
my reeponeibllity t.notify the cuPmt Of the
smiumeorm Signature of Applicant Date
a ZAll roof coverings to be Class "B" or better
Date