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CITY OF CUPER INO
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PERMIT NO.
10343 N WOLFE RD
MONZA C0NSTRU9MLQN_CQMPAN]IL_
09050064
NAME:
INC..
PERMIT ISSUE DATE
PHONE
STIN DR. ST -Fr i
Q-7 Inn 12GQ9
S A CONTROL NO.
(480) 425-8200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CO ACrOR'S DECLARATION
Job Description
1 hereby affirm Nat I an licensed under provisions or Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full face and effect.Z
COMM' L r,I ADA IMPRVMNTS BTHRM NEW FXTRS TILE
Dau: naaCla`s — Liecw, iturano,^ n
LMBING LIGHTNG ADA LIFT @BAR AREA NEW BAR
CEILING
ARCallbeuedaspuARATION
1 understand my plans slut( he used u pubic records
NEW AWN:;:NG & LIGHTING @EXTERIOR & PAINTING; NO
LicensedPmfessionaf
OWNER -BUILDER DECLARATION
1 hereby ailuro that 1 am exempt from Na Conuactar•s Uccnse Law for the
following reason. (Section 7031.5, Buthness and Professions Code: Any city or county
which requires a permit to cornsuuct. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
that he IS licensed pormant to the provisions of the Convacwra Ucense LAW (Chapter 9
3q. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
2 0 0 O O 0
that he Is exempt therefrom and the basis for the alleged exemption. Any violation or
APN Number
Occupancy Type
Section 7031.3 by any applicant for a permit wbjects the applicant to a civil penalty or
rat mom than five hundred dollars (5300).
31620055.01
❑ L as owner or the property. or my employees with wages as their sole compensation,
Required Inspections
will do the work and the structure is not intended or offered for sale (Sec. 7044, Business
and Professions Code The Contractors License Law does not appy to an owner of
ply who builds or improves thereon, and who does such work himself or through his
own employers, 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
salt.}
❑ I. as owner of the property, am exclusively contracting with accused contractors to
constrect the project (Sea. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply to <a own" or property who builds or improver thereon, and.
who contracts for such projects with a eonuaetor(s) licensed pnusuant to the Conuactoes
License Law.
❑ I am exempt under Sec, . B & P C for Nis reason
m" Date
WORKER'S COMPENSATION DECLARATION
I hereby &(Term under penalty of perjury one of the following declarations
I have and will maintain a certificate or consent to self -insure for Workers Compcn-
ion, u provided ser 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 or the work for which this permit is Issued.
'
My Warmers Compensation Insurance amu and Policy number are:
Cartier. Polley No.:
CERTIFICATE OF DFE_MFnON FROM WORKERS'
COMPENSATION INSURANCE
rlLis section need rot be completed U the permit is forone hundred dollars ($100)
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 u b be.9rapo subjen b the Worfeat Compensation
Laws of CCIifanirBa+y�'�— i '
AppBcam ��77��
.
NOIICE TO A4'PLCANI IL a making this CeniOcate of Exemption, you should
become subject to the worker's Compensation provisions of the labor Code. you muss
forthwith comply with such provisions or this peanit shall be deemed revoked.
I
CONsmuc-nON LENDING AGENCY
I hereby ofrum that Nora G a coMructinn lending agency for the performance of
the work for which this permit Is issued (Sec. 3097, Cn. C.)
'
Lenders Name
,
Landers Address
I l certify that 1 have rad this appWation and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws mladng to
building construction. and hereby authorize representatives or this city to triter upon the
ahove-mentioned property for lospcnion pwposes
(We) agree to save, indemnity and keep harmless the City or Cupertino ajunst
j in CO 3q, judgments, costs and expos Pe which may in anyway acme against said City
� In COnieg0elleC Of Ilfe granting or this permit.
APPLICA STANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date /
SOU EGU
? 9 09
Re -roofs
Type of Roof ?�S
Signature Applitan✓Conuaclor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the apphcart or future buiiding occupant nose or handle hwwdous material
u defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
,'`'es Yes Na
All roofs :;hall be inspected prior to any roofing material being installed.
If a roof i:; installed without first obtaining an inspection, I agree to remove
Will the applicant or rutum building occupant use equipment or tkvi= which
emit hazardous air contaminants as tkrhned by the Bay Area Air Quality Management
all new materials for inspection.
District?
1(Q
❑ Yes No
1 have mad the haardous materials requirements undo popes 6.93 of the Califor-
nlaHrslth&Safdycode.Secd=25505,25533aru17SS34.lundcrswW"tfthc building
does not curtenty have a tenant. that B is my responsibility to nodry the occupant of rhe
requircmcnts wissaarcoera cutifeamorOccupancy-
Signature of Applicant Date
7-1 n• 7
.
All roof coverings to be Class'%" or better
Owner or—iuftrilEd agent Date