04020140 CITY OC CUPERTINO
RUILDIN G DIVISION PERM ,CONTRAC X RINFORMN
BUILDING ADDRESS: PERMIT NO04020140 402014O
ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
n : BUILDING PERMIT INFO
RCHITECf/ENGINEER
BLDG ELECT PLUMB MECH
0 0 0 0
Zen,F
LICENSED CONTRACTOR'S DECLARATION Job DCSCrIpIlOn
ereby affirm Nat 1 am licensed under provisions of Chapter 9(commencing
i Section of Division 3 ofthc Busincuaml Professions Code,and my license is
">` eaWe e l -047- LI� 7oS o'LI SIGN--THINK TANK LEARNING
Lices
—o2-caoil" r L^ r ' CONTRACTOR: CYPRESS SIGNS UNLITITED, 'INC
ARCHITECTS DE RATI N un)Zl of
�i sednderstand my plans shall Mused u ublic records
z U
30� PmfeuinnalOWNER-BUILDER DECLARATION
Maso .(Rem that 1 cxcntpt Gam the Conuacmr's e:Any c Law for tMo massa caned t 7031.5.ourBusiness and sae,de oli h.at:Any city or county
xm Which mgaims a-.1 m tons he aper,improve.demolish,ix e.sir any unclose
w—'^ pot heitsce,ande,also requires the applicant for such permitmflc aligned nammcm
plot he pursuanua the provisions of the Contractor's License Low(Chapter9 Sq.Ft. Floor Area Valua[i0, 45O
a (eammemeingwith Scotion 7")of Division 3 of On Businessand Profusions Code)or
4
y $ Net he u exempt t%Ifram and the basis far the alleged cxmption.Any A.ladon or
sccdon]ovs bYMY appfeantroraPermit sabjccu the.pplkanna aeiall Penalty Of APN Number Occupancy Type
not more than fs hundred dollar(5500),
01.u owner of the property.or my employees With wages M their sole compenotion, 36201022 . 00
and Pr Newark.and Nc he lion Consnmi License
aroffend awdos,not apply Loin ownBuser
Required Inspections�
ess
and enywhiou builds
The Contactor's rad who Lew deo not apply lf an owner is q
Own enywho builds or improves ch improvement
and who am not wix intended quit ror edthroughhis
own employees.provided mho such improsmw t arc not arof mpleti ed for We.if. �y
however,the building at improvement is said within ox year of improv far We owned T��j/�/
While will have dm burden of proving Nat he did not Wild or improve far purpose of I
ole.).
1,as owner of the property,am exclusively contracting with licensed contractors to
construct Ne project(Sce.7014.Business and Professions Cade:)The Contractor's Li.
ceme Law does not apply to an owner of pmpeny who Wilds of improves Raman.and.
who contracts for such pmjccu with a comraluohi)licensed pursuant to the Contraction
Me Law.
Morpt under See ,B&P C for Nu mason
nee Data
---------VORKER'S COMPENSATION DECLARATION
1 hereby arBren under penalty of perjury one of the fallowing declarations:
1 has and will maintain a Canifam of Content to sel6insum far WorkersCompen-
otion,as provided fix by Section 3700 of on Iwbar Code,for the perfarmance of dm
work for which this Permit is issued.
1 haveand will maintain Worker's Compensation Insurance,u required by Section
J]00 of Ne lobar Code,for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance artier and Policy number am:
Cam, Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisxctiwne I 1bQcomplemJ irtbe Permit is for one hundred dollars($100)
or Ices.)
1 rectify that in U performance of work for w h this permi u issued,l shall not
emplWany pc n hymanncrsa mWmmc jeam th W rk r Campcua0on
Laws of California a¢
Applicant -e—
NOT��CEE��TO APPLICANT:If,afterCom cosat Nis provisions
M Labor io d you should
bccalpYsuM1jcn m Nc Workers Compcnotion provision of the Labor Cade,you must
.7. Z forthwith comply with such provisions or this permit shall be deemed ocvnkcd.
Z O CONS RUCTION LENDING AGENCY
1-+w Ihemby orf rot that Nem iso eavtmction lending agency roe eche perfurmanw of
the work fur which Nu permit is issued(Sec.3091,Civ.C.)
fa7 F Lender's Name /
LL Under's Address
UC) I certify Nat I haw read this application and sum that the show information is
!i. carnet.I agra m comply with all city and county ordinances and sum laws totaling to
0 V MikBo9constmction.a ndhembyaudodmmprt nubs OfNiseitymcnmrupnn Ne / 167)Uahovcmcmiuned properly far inspection purposes.
(We)agree to save,indemnify and keep harmless the City of Cupertino against
liabilides.judgmen¢costs and expenses which may in any way accrue against said City(„)z M_=
fthcgmni of this permitt
NVif COMPLY WITH ALL NON-POINT Issued by: Dat
11
IL
—��Z 9 Re-roofs
ignawrc of ApplaHAZARDOUS MATERIALS DISCLOSURE Dalc Type of Roof
Will the applicant or future building occupant senor,or handle hazardous material
u dcfincd by the Cupertino Municipal Code Chapter 9.11:and do Health and Safety ,
CWC Section 25531(x)] All roofs shall be inspected prior to any roofing material being installed.
n Yo 1pu
Will the applicant Or Noun Wilding Occupant use equip rno or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air contaminants as dcfincd by the Bay Area Air Quality Management all new materials for inspection.
D'strin?
Yes [�y
1 have mad the hazardous materials myviremenu under Chapter Q95 of the Ca iro,
nialka�h&SafctyCOdc.Sccdom25 5.25533and255]4.Iun&n=dthssirNc Wilding
dss�rot curxn0 atenanLth tismylr SWnsibilitymnotifytWoocupantoftha
mgnik entswmanaU.Manp 1.1soom or.cert;fi maraeupancy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner ru�thorned agc ��__ CDam
CITY OF CUPERTINO
Ga SIGN
T
OF
•CUPERINO PERMIT APPLICATION FORM
APN# Date:
3 co z - p l -'oZz l /ZC) /0,1.
Building Address:
10(o5-0 6U66 16) ,
Owner's Name: 'fN irJit TR O Phone#:
-roHn �,4c�cso�J 4o6--?7-)- 0400
Contractor: License#:
Contact: ^ Phone #:
�J s rJ/Jl5 Gi2u ,1D� 408 - Zz- -Z 6 00
Applicant/Contractor:
Buildin P t Info:
Bldg / Elect Plumb Mech
Jo escnption: ADD NAU.- S16 'To
esidential: V�� Commercial: CorLEr,�- r3u Vi IG
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
B ERMFEE Bldg Permit Fees BUILIDNG
PLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial . BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG
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CITY OF CUPERTINO .....an
BUILDING DIVISION PERMIT CONTItACT�ORNFORMAIION
BUILDING ADDRESS: PERMIT N004020140 4020140
OWNER'S NAME: PERMIT ISSUE OATS
is
WE: SANITARY O. '12 ONTR
COL N0.
ARCHIIECTMNGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LOp LICENSED CONTRACTOR'S DECLARATION JobDescri Description
C I hemby affirm Nat 1 am licensed under provisions of Chapter 9(commencing p
b with Seebn 7")of Division]alone Business and Professions Code.and my licenmu
^ in full full fo a neo
5�= Licenseema 44,,I_V4Z 7€s 621 SIGN--THINK TANK LEARNING
Z—o Dam 21 yO Conti r c r CONTRACTOR: CYPRESS SIGNS UNLITITED INC
'l- ARCHITECT'S DE RATIN uay,lysf t�� s
CC I understand my plans shall W used ublic records
JyU
3tat; Licensed Professional
OWNE nxe
aU1L0ER DECLARATION
C.muonvION
1 batch, from that I em exempt from dm Cenor's License Law fur tW
0 o following mason.(Section 7051.5.Business and Psoficbimu Cade:Any city or county
m Z which mquma a permit in construct.altar.Improve,demolish,or repair any structure
prior m its issuance,a)So rect iru the applicant for such permit or file a signed su ement
Fc Nat he is licensed pursuant to the provisions or NeComment's License Loa(Chapter 9 Sq.Ft. Floor Area Valuatio`9450
(commencing with Section 7000)of Division J of the Business and Professions Cole)or
Nat W u eacmpt therefrom and the basis for the alleged exemption.Any violation of
Schon 7071.5 by any applicant for a permit subjects Ne applicant in a civil penalty of APN Number Occupancy Type
not tort Nan firs hundred dollars 023(X)}
❑1,u owner ofthe pmpasay,m my employes with wages ss their sale eompenutlan, 36201022 . 00
will do Ne work and be structure is not intended or offered forsak(Sce.7044,Business
and Professions Cade:The Commences Umnse law does not apply to in owner of Required Inspections
srosenywho builds or improves durnean.and who doessuch work himulf orthrough his
awn employes,provided Nat such improvements art not intended oroffered forme.If.
however,Ne building or improvement is sold within one year of completion,Ne owner.
builder will have the burden of proving Nat he did not build Or improve rot purpose of
,ala.). Y G vim.R:k ASL ika. '
❑I,as owner of ct Sec.70y..B exclusively contesting with licensed contractors m
canstrvn it not (Sec.]Odd.Business and property
who ui Calds or improves,The snuanor. nd n
ccnm law dots t such ply m an ish a or proper(wmnsedds or nt toMComm,ces 3 2004
whome,Lo
u for such projear with a contactor(s)limnxd pursuant the Commences AUGF'[V l7 Fav
L are Law.
aemPt under Scc. .B&P C for Nis msson
Owner Data BUILDING
WORKER'S COMPENSATION DECLARATION
1 hereby affum under penalty of perjury one of Ne following declarations:
❑1 haveand will maintain aCerifiamof Coommu self.lmumTorWorker',Campen-
union,m provided for by Section 57110 of be labor Code,for Ne performance of the
work for which this permit is issued.
❑1 have and will maintain Worher's Compemation Insurance,as required by Section
77W of Ne labor Code,for Ne peKomtance of Ne wool for which this permit is issued.
My Woolcrs Compensation Insurance artier and Policy number are:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thisxctianne o completed ifthe permit is for one hundred dollars ISM)
or ku7
I certify Net in N performance of work for h Nis Person is issued.I shell nut
employ any pers n ymanncrsoa to Wcome �jecuoth W k Cc sensation
laws of Califo,I am
Applicant
NOT�tt�CEEJ�TO APPLICANT:If,after Compensation
Nis csion o of Exemption.you should
NW
ith comply
the Worker's proComsor Mis Permit
Of de lad! Cade,you muss
.,Z roMwiNeomply with such pmvinnm or Nu permit shall be accord!mvatrd.
z O CONSTRUCTION LENDING AGENCY
[+ 4 1 Withy affirm Nm at Neis a construction lending agency for M e performance of
1a > Ne work fur which this permit isissued(Sec.5097.Civ.C.)
tat Q Lender's Name
L4
Z Lcndces Addmu
J
L)Q 1 moil,Nat I has mad Nis city
and
and sum ms Ne above information o
II. F' concur.1 agree et comply with all city end county ordinances and sum laws relating to
QU atowe-menblding uvd pmNnd hereby euNorimrtosses. tivcs of this city mcnmr upon tW /
} IJ.1 shove-(Wc) ,d w cony for inspection puryoms
fY liabilitie�judgmenu,cosuandevnf ser whicit h may
mkssthe City of Cuairrosidrm City
r fn pun ymany way accmc vgainst said City
U z roto neeof the gnmi of Nis permit.
A PPLICA UNDERST S ILL COMPLY WITH ALL NON-POINT Issued by:S4(12� Da
SOURCERE ULATION .
�Z FA Re-roofs
tgnaturc of Appl Data N
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwm building occupant More or handle hanur ous material
as deRred by Be Cupertino Municipal Cade.Chapter 9.12,and Mc Health and Safety
Code.Sccdon 25512(a)? All roofs shall be inspected prior to any roofing material being ins
❑Yes tailed.
�o
Will Ne applicant or future building occupant its,equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
miI hacamoa air mnmmimmis as dc0ned by the Bay Ama Air Quality Management all new materials for inspection.
Dis in?
❑Yea $v_..
1 have mad the hasafdaus materials requieemcnu under Chasms 6.95 of the Califor-
niaHcal &S cry Codc,Sectiom25505.2555}ant1is55d.lun&nrsm mifthc Wilding
dna t currentl arc v¢Hans N t is alienability in notify the a¢upant of Ne
equi menu which u9 hemet p wisdom Ora Ccnfi ro
iof cupanry. Signature of Applicant Date
owner o amoriara ase Z Dam All roof coverings to be Class"B"or better