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CITY OF CUPERTINO
PERMrr
BUILDING DIVISION
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BUILDING ADDRESS:
PERMrr NO.
10343 N WOLFE RD
MONZA CONSTRUCTION
OWNER'S NAME:
INC.
PHIUM L$UE DATE
PHONE'
A CONTROL NO.
(480) 425-8200
ARC WTEC7ENGINEER:
BURRING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CON•IRACrOWS DECLARATION
Job Description
I hereby affirm that l am licensed under provisions of Chapter 9 (commencing
with Section 70D0) of Division 3 of the Business and Profcssimns Code, and my license is
in full force and effect.
RMV EXTNG BATHRMS & PREPANE FOR NEW
License cla:a Contractor
FINISHES(400SQ)
ARCHITECTS DECLARATION
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Conuactors Lkcnsc Law for the
following reason. (Section 7031.5. Business and Professions Code: Any city or County
which requires a permit to covistruct, alter, improve, demolish. or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 70D0) of Division 3 of the Business and Professions Code) or
4 5 0 0
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
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Section 7031.5 by any applicant for a permit subjects the applicant to 1 civil penalty of
riot mom than five hundred dollars (ssoo).
31620055 .00
❑ L as owner of the property, or my cmpioyces with wages ss their sale compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (See, 7044, Business -
and ProfeWons Code: The Contractors Licensc Law aaa not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
ova employes, provided that such improvements are not Intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
sale.).
L as owner of the property, am exclusively contracting with licensed contractors to
ownertruct
consthe project (Sec. 70". Business and Professions Code) The Contactors U.
cease Law does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a conuwwr(s) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt tan Se01 B lit P C for
Owner Date
WORICFA'S COMPEN5A N DECLARATION
y affirm under penalty of perjury one of the following declarations
�haftz:nd
will maintain a CertiBcam of Consent toself-insum far wmtees compcn-
vase
Zon, provided (or by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
.
3700 of the Labor Code, for the performance of the wort for which this permit is issued
My Workers Compensation huunttce carrier and Policy number arc
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed If the permit Is for one hundred doll= ($ I00)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. L
Appllcuu
NOTICE TO APPLICANT: If, alter making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be darted revoked
I
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there Is a construction lending agency for the performance of
the work for which this permit is issued (Sec 3097. Cdv. CI
-
Lcndees Name
Lenders Address
I I certify that I have Tad this application and state that the shove information is
'
' conecL I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above -mentioned property for inspection purpose&
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgments, cogs and expenses which may In any way acme against said City
' in consequenc�u of drag o this pernhL
APPLICANT A AyD WILL C P IT7i ALL NON -POINT
Issued by: Date
SO CE R NS
Re -roofs C7
Type of Roof
LL/
ofApph HAZARDOUS MATERIALSDISCLOSURE
W it the applicant a future building occupant store or handle haardous material
defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 23532(a)7
r No
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fis\tine building occupant use equipment or devices which
emit haardous air contaminants as defined by the Bay Area Air Quality Managcmcni
all new materials for inspection.
Disuict7 ,fry
❑ A Yes No
I have read the haotardotts matcdsb requirements under Chapter &95 of the Califor-
nia Health do Safety Code, Sections 25505. 25533 and 25334. I understand that if the building
dots currently c a t, it is my rWponsrWIdty fy the occupant of the
req outs sea m or tree f to ref
Signature of Applicant Date
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All roof coverings to be Class '%" or better
o authorL=d agent arc
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