08080041 CITY OF CUPERTIN0
BUILDING DIVISION PERMIT coRACTQRANF01 ATj9N95
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BUILDING ADDRESS: PERMIT NO.
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21.546 MONROVIA ST TBD – TO BE DETERMINED 08080041
NER'S NAME; PERMIT ISSUE DATE
08/05/2008
SANITARY NO. CONTROL NO.
ARCHITECTIENGINBER: BUILDING PERMIT INFO
BLDG ELECT FLUME MECH
LICENSED CONTRACTOR'S DECLARATION
I hereby afflorn that I am lice ad under provisions of Chapter 9(commencing Job Description
with Section 7000)nOlvition 3 offt Business and Professions Code,and my license is CONSTRUCTION 'TRELLIS
llriweemni.from.12, —4 0
mllcl� 0
C. Cl' Coln
F'P�A IlHils DECLA&AeK-r-�
I understand my plans Asti k used as Public twords
Licensed Professional
OWNER-BLEILI)ER DECLARATION
I perchy affire that I am exempt from ft Contrwor's License Law for the
following reason.(Section 711313,Business and Prefessions Cow:Any city or county
which requires a permit u,construct, IW.Improve.derrodish.ore any structure
Valuation
5 (commencing what Section 700M of Division 3 or the Business and Powficanons Code)at $1200
'it las Is exempt therefrom and Use lands for the alleged exemption.Any violation of
prior to its ousswc.also requires the applicant for such permit to rile%signed swereen,
low he I.licensed .t W Ew proushanxts the Contractors Lim.U.(chapter 9 Sq.Ft. Floor Area
Section 7031.5 by any applicant for a Much subjects the applicant to a civil parafty,of
me,more man ave hundred d.liburs($500). 3 5 6 2 3 018 ,W Number Occupancy Type
0 i.na offtFopwy.wmy=pioymwith"guuftirmlew wmdon. — I
will do the work.and dusunnoure is maimorded"Offered forrole(Sec.7011.Business
W Professions Coca:The Committees License Law does Out apply min Owner of Required Inspections
property who builds or improoss,Lhown,and who does such work himself orthrough his
Own employees,provided that such Improvements are not Intended Oreffmad forsale.If.
weaver,the building orimprownwast is mid within one you of completion.the owner.
builder will have are thrown of proving dust no did ran budial or improve for purpow of
sals.).
[3 1,as Owner of the Property am aclmlvcly contracting with licensed cantransue,U,
construct tiro pmjca(Sec.7014,Business and Professions Code)I=Conuxwes U.
cause Law does not apply or an owner of property who buRds or Improves pereen,and.
dparommitotseCantrasome,
Lice=Law.
❑1 am exempt under Sec .B SEE P C for this mossm
—Dam—
WORKER'S COMPENSATION DECLARATION
I hereby affloto under immilty,at perjury was of me,following deGarmwe
n I havested will maintain.CarthricatordC.Ustrut to scIf.hurs.ferWorkme.Congo.
sation,Us provided for by Section 3700 of the Labor Code,for ft Performance of me
worl,far which this Permit is issued.
❑1 cars and will noomm.W ,Comparmordom I...Us wimead by Sued.
3700 of me Latuar Code,for the pedomentrace of me work for which this Permit is Iowa
My Worker. ompenutian I..coot.or and Poll,rioubm
Cartier. Policy No.;
�CAM OF EXEMPTION FROM 0�
COMPENSATION INSURANCE
O'his auction Used Out becounpimcd time Permit 1.forrese hundred 011.(1111011)
or ten)
I CcuifY that In the Performance of the wort for which this Permit is howd.I shot not,
employ anypenew in my mormars,as 0 baoma subject ur the Woftro'Compmessfor,
law.m'California.Cate
Applicants
N0710E TO APPLICANM If.after making this Cerfincom of Exemption,you should
become subject to Else Workmen Comixeruadon provisions of one,Latmur Code,you muss
OfonAwitla comply with such provisions Or this permit Nall be warned reveltud.
zry CONSTRUCTION LENDING AGENCY
(hereby affins,that them 1,a construalino lending agency rnr the Performance of
ai > the work for which this Permit 6 issued(See 3097,Civ.C.)
Lenders Name
z lenders Address
U 0 1 cerafy that I have mad tho applicatuto W thato thad are above mromamfon ot
gi,E correct.I agree to empty with all city and county ondInarstas and stme laws mliang to
0 Wilding construction.and hereby aummix:MPmsenMilM Of thin City to Enter upon ft
slaw.-mommared property for inspection purposes.
py (We)ot"u,save,indcrecify and soup harrults,the City of Cupertino against
t,i liabilities.judgments,costs mul operates which may in any way accox,against and Chy'
Z in consequence of the jramn,of this ranormt.
APPLICANT UNDERSTANDS AND W by
SOURCE0 _]�LILL_COMPLY WITH ALL NON-POINT Issued Date
Re-roofs
Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the pplicanimr:7
'U'luildi nomorial
pan !112" Health and Safety
as dclinual by ft Cupertino N 11 cc P. 9m
Sued..25532(.)?
0y. �N. All roofs shall be inspected prior to any roofing material being installed.
Will flat Applicant or future Wilding occupant use Equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
moot haeard.un ah,Ecourno.7 cleared by me Bay Area Air Quality Management all new materials for inspection.
District?
[-]Yes
I have mad the boardous materials requirements under Chapter 6.95 of the Califor.
-I.Health AE Sfmy Code,Seetions,25505,25533 awl 25531.1 undmannal that dave bubfing
does not CurroulY have a meart.chat It IS My responsibility to notify ft wenown Of the
require khmuR =Lpd.IWIU.anmOf.Ce kamafOccu �1 Signature of Applicant Date
own s�f aZtRa—drt—dation, All roof coverings to be Class'/W'or better