04120097 (2) CITY OF CUPERTINO " .�`
- BUILDING DIVISION PERMIT - "'CON,"OTORANFOT.tMQTION`:x -:
BUILDING ADDRESS: MBROWN CONSTRUCTION, INC PERMIT N9b4120097
21505 MONROVIA ST
OWNER'S NAME: PERMIT ISSUE DATE
MONA LEI 702 S . DANIEL WAY 12 /19/9,004
NE: SANITARY NO. - - CONTROL NO. '
(408) 260-1260
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 � (�
LOp LICENSED CONTRACTOR'S DECLARATION Job DeSCrI 1100
C 1 b, me that 1 am limnscd under provisions of Chapter 9(commencing P
U with tion )OfDI on3oftM BuvrrssarN Pmfusiav Code.andmyl)caPcis
� y roma aaneer�hj ( LG REROOF-LIGHT TILE
j n 2 License Class Liell,
nJk,G Da —
? ECLIVATION
Us 77U undo n plan ehall hcARC ua d cards U 1i•' /' /
3
a�
Licensed Pro anal ,.
OWNER-B4 ER DECLARATION +'
f 1 hereby aIB.that 1 son rop,from doe CanVxtofs License law for the J
n O following mason.(Section 7031.5,Business and Professions Cale:Any city or county _ n
K a m which ax.h a permit U,tomatoes.tiler,improve,dcmollah.or repair any structure D /AO^a
- G prior ad its issuance.elan requires the applicamfearsuch Mrmitto file a signed stateent `)�/ /�`, .-_J
H< WtheislictnseJpursuanuethcnrovisionsaftheConuxmr'slJcenulaw(Chanter9 Sq. FL Floor Area ✓J r„ Valuation
o (commencing with Section 70D0)o(Division 3 ofthe Burricasand Professions Code)or
XV that he is exempt therefrom and the honk far the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects Ne applicant to a civil penalty ofCrO Occupancy 0 � " u 'r OCCU Type
ant roam It.five hundred doll.(antro). P, Y YP
❑1.uowoesofthepropmy,ormyemployeeswithwageutockgokcomp flon, --
willdo she work,and the someone e
ne isnotinaded or offered foraale(Sec.7W,Business
and Profession"Coca:The Colossuses License Law does not apply in in owner of Required Inspections
property who WiIdamimp,a.0 themen,and whodonsuchwmk himselfmthrough his -
Own employee,provided per such improvements are unintended oro@ed forage.It.
however,the building or improvement is gold within one year ofcompleuon,the Owner- ,
builder will base the baaLen of proving that he did not build or improve for Foliose of '
sale,).
❑1.as owner of the property,am exclusively contracting with licensed conuacmrn I.
construct the project(Sce.70aa,B omens and Pofessai Code:)The Convector',U.
me law does not apply to an owner of property who builds or improves theeon,and
who conuacufar such projecs,with a conuacer(s)Iiunwd pursuant w tk Committees - -- - - - -
License Law. ..,
❑Iamaicmptander Sea ,BA,PCfmthis.U. .
Owner Data
WORKER'S COMPENSATION DECLARATION - - — - - -
1 Mreby affanO under Penalty of perjury one of the following drelantions: - - - -
I have and will maintain"Certificate of Consent to.ulf-insure for Warks/s Comptn-
=ton,as provided for by Section 3700 of the Lobar Code.for the performance of the '
work for which this permit is iumd. -
(]1 have and will maintain Worker's Compensation Insuranm,or acquired by Section - -
3700ofthe Labor Codc,for the perlmmancee of the wort lm which this permit is issued.
My Workers fiopo Imm emberand Policynumberam:
Ca tX.Y �A Policy Na.: 1 O
CERTIFICATE OF EXEMPTION FROM KERS'
COMPENSATION INSURA
(This section mad not becomplced ifthe ration,lc,mio forme hundm-0dollars(5100)
or Its.)
I certify that in It.perfmor.of tht walk for which this permit Is issmd,I shall oat
employ any person in any mane,sou to became subjmoto one Work.Compensation -
Laws of California.Data
Applicant -
NOTICE TO APPLICANT:If,after making this Ccnilicate of Eacmption,you should -
become subjmt to the Worker's Compensation provisions of the Labor Com,you must
., z foMwith comply with such Provisions or this permit shall be decreed revoked.
'Z O CONSTRUCOON LENDING AGENCY
F+ Ithereby affirm that then is a construction lending agency ror the performance or
Cv > the work for which this,parmit is bound(Sm.3097,Civ.C.)
aLanders Nam.
7 z Landersaddress
U C) I ecnify that 1 hese read this application and sense that the abets information is
0 WildaCentel.I agree to comply with all city and county ordinances of and senor laws relating to �.
D U adow-nommng ucil ro and bombs euthonp rposes entivcs of this city in cowl upon ons
shove (We)
for inspection keepher
(Wc)agree to cost,indemnify and keep may
in m the City of Coptnaft it against
h inconseque consequence
of thecmtsand eftcnsu which mey in any way same agaiutsud City
t.>z APPLI AW of UNDERSTANDS
Sthis permit Issued by: Date
r. APPLICANT UNDERSTANDS AND WILL C MPLY WITH ALL NON-POINT
SOURCEREG Ns.
Z Re-roofs
_Y97UaofApptFdYVC.numi
HAZARDOUS MATERIALS DISCLOSURE - D— Type of Roof
Will the applicant or future building occupant store or hmadle h emlous mamnal
Us defined by the Cupertino MF."'Fal Cods.Chapter 9.12,and the Hcalth and Safety
Code.Section25532(a)7i All roofs shall be inspected prior to any roofing material being installed.
Yes win tut anphcant or rmolding accupont use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hammous air contaminants as defined by the Bay Arta Air Quality Management all new materials for inspection.
Dishkn J P
(]Yes fc
I have raw/thehaaamo materials requircmenu under Chants,6.95 o(de Califon /0
nuHwlth'Safeo Code.S=D=25505,25533and25534.IundeneM ifde Wilding
does amt corm 1 ha a muscat,that it k my responsibility m imtifyYm Occupant n(the /. Ta 111 C
rtquimmen stbcme Pro r oaanccor.ce�`of�re y. Signature of plicant Date
owns,argomornn agentD,m All roof coverings to be Class "B"or better
CITY OF CUPERTINO
I� 1 of 1 PERMIT RECEIPT OPERATOR: seem
COPY # 1
Sec: Twp: Rng: Sub: Elk: Lot:
APN . . . . . . . . : 35623030.00
DATE ISSUED. . . . . . . : 12/15/2004
RECEIPT #. . . . . . . . . : 28052
REFERENCE ID # . . . : 04120097
SITE ADDRESS . . . . . : 21505 MONROVIA ST
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : MONA LEI
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-4803
RECEIVED FROM . . . . : HAGAN/KM
CONTRACTOR . . . . . . . : CHRIS BROWN LIC # 25108
.COMPANY . . . . . . . . . . : MBROWN CONSTRUCTION, INC
ADDRESS . . . . . . . . . . : 702 S. DANIEL WAY
CITY/STATE/ZIP . . . : SAN JOSE, CA 95128
TELEPHONE . . . . . . . . : (408)260-1260
OE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
---------- ------------- ---------- ---------- ---------- ---------- ----------
BPERMFEE VALUATION 20, 000.00 277.56 0.00 277.56 0.00
BSEISMICRE VALUATION 20,000.00 2.00 0.00 2.00 0.00
---------- ---------- ---------- ----------
TOTAL PERMIT 279.56 0.00 279.56 0.00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ------------------
OTHER 279.56 AMER EXP
TOTAL RECEIPT 279.56
•
CITY OF CUPERTINO
� REROOF
CUPER`iNO PERMIT APPLICATION FORM
APN# Date:
Building Address:
ai5v5onroul� Sf.
Owner's N e: Phone #:
Ng
'�n o- Le WW'.
ContraG{oPhone #: , 2(Y Licensg#:lti
Contact: Pone#: Cupertino Business License#:
�`rtswv� • 2�U �� v �S/Q�
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) Other(Specify) I L
Number of existing coverings Provide I.C.B.O. Report# 2 ,ly
❑ To be Removed f Provide Mfgr. Installation Specs.
• I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: (p
Job Description: _ tJ� �—�� — 1, 0 r14
Residential Commercial ❑
Fire Zone: Yes ❑ No ❑ Confirmed with Planning Det. if
there are anrestrictions: LJ
o P 'ecy Type of n cacti Occupancy group:
i
e Fee ID Fee Description. Fee Group
BPERMFEE BldgPermit Fees BUILDING
BENERGY Ener BUILDING
-- BSEISMICRE Seismic Fee Res BUII DING
BSEISMICOM Seismic Commercial BUH2NG
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING