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09050069 CITY OF CUPERTINO BUILDING DIVISION PERMITQ�N. BUILDING ADDRESS: PERMIT NO. 10343 N WOLFE RD MONZA CONSTRUCTION COMPANY, o9o5n069 NER'S NAME: INC. PERMIT ISSUE DATE r•Tz+ _ TFT AT�TTI HI� � NnUNE: S A CONTROL NO. (480) 425-8200 ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH o p C LICENSED CONTRACTOR'S DECLARATION Job Description U U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Z with Section 7000)of Division 3 of the Business and Professions Code,and my license is O=yW in full force and effect. Z2 ifs`f TEMP PERMIT; ADA BATHRM UPGRADES;ORIG L 'Daz LiceneCl . -O Contractor \Zn -PERMIT GOOD THRU 6/14/2009; NO INSPCTNS ua Date ARCHITECTS DECLARATION � AFTER 6,'14/2009 oC< l understand my plans shall be used as public rcctK�� �qU Cy Licensed Professional 0W OWNER-BUILDER DECLARATION 03 1 hereby affirm that 1 am exempt from the Contractors License Law for the p O following reason.(Section 7031.5,Business and Professions Code:Any city or county K m Pi which requires a permit to construct,alter,improve,demolish,or repair any structure Zprior to its issuance,also requires the applicant for such permit to file a signed statement _< that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 ;>q.Ft.Floor Area Valuation Yt-G (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $100 y that Ise is exempt therefrom and the basis for the alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type not more than rive hundred dollars($500). 3 16 2 0 055 . 01 ❑I,as owner of the property,or my employees with wages as their sole compensation, will do the work and the structure is not intended or offered forsalc(Sec.7044,Business Required Inspections and Professions Code:The Contractor's License Law docs not apply to an owner of fl P property who builds or improves thereon,and who does such wort himself or through his own employees,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.). ❑1,as owner of the property,am exclusively contracting with licensed contractors to construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- cense Law does not apply to an owner of property who builds or improves thereon,and. who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's License Law. ❑1 am exempt under Sec B&P C for this reason --ner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under penalty of perjury one of the following declarations: ❑I have and will maintain a Certificate of Consent to self-insure for Worker's Compen- sation,as provided for by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. I have and will maintain Worker's Compensation Insurance,as required by Section 3700 of the Labor Code,for the performance of the work for which this permit is issued. My Worker's C�om.(p�enaau Ins�,a�nce caricr and Policy number am: Cartier. ' "`^ o+' Policy No;l ul ` CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (This section need not be completed if the permit is for one 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 as to become subject to the Workers'Compensation Laws of California.Date Applicant NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should become subject to the Worker's Compensation provisions of the Labor Code,you must Oforthwith comply with such provision or this permit shall be deemed revoked. Z'. CONSTRUCTION LENDING AGENCY [~-n rte.. I hereby affirm that there is a construction lending agency for the Performance of (Y> the work for which this permit is issued(Sec.3097,Civ.C.) QLender's Name a Z Lender's Address U O 1 certify that 1 have read this application and state that the above information is LL►" correct.l agree to comply with all city and county onfinances and state laws relating to 0 V building construction,and hereby authorize representatives of this city to enter upon the Uabove-mentioned property for inspection purposes. a (We)agree to save.indemnify and keep harmless the City of Cupertino against p.4 liabilities,judgments,costs and expenses which may in any way accrue against said City U Z in consequence of the granting of this permit. '- APPLICANT-UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOARCE REGULA I-- ' r�Y-6r-1 �.. Q�i Re-roofs Signature ofllpfi t/Contractor D81 Type of R�Of HAZARDOUS MATERIALS DISCLOSURE Will the applicant or future building occupant store or handle hazardous material as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety rode,Section 25532(a)? All roofs:,hall be inspected prior to any roofing material being installed. ❑Yes No Will the applicant or future building occupant use equipment or devices which If a roof i:.installed without first obtaining an inspection,I agree to remove emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new m iterials for inspection. District? ❑Yes VN. 1 have mad the hazardous materials requirements under Chapter 6.95 of the Califor- _ �" ._ 5 ( (e�-C j nia Health&Safety Code,Section 25505,25533 and 25534.1 understand that if the building (� , J does not currently have a tenant.that it is my responsibility to notify the occupant of the requirementswhich muffbe—ink or a certirtcae n empancyC 17Signature of Applicant Date -1 -- - All roof coverings to be Class'``or better Owner or authorized agent Dae