08060148 CITY OF CUPERTINO �
BUILDING DIVISION PERNIIT �^yCONTRACTOONFORMAT, '
xa ,a'e3^''e 9zarF:'.^u"I M15 ;n'k,5s u.�,Aa-hy9 ".
PERMIT N0.
BwLl�Irf,G TES DE ANZA BLVD GOLDEN GATE SIGN CO 08060148
OWNER'S.N�AIME.: FERNUT ISSUE DATE
CIVIC PARK CUPERTINO LLC 711 INDEPENDENT RD 07/02/2008
NE: SANITARY NO. CONTROL NO.
(510) 366-3838
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u o o LICENSED CONTRACTOR'S DECLARATION IOU DCSCTI IIOn
C I thereby affirm Hut I am lhemmd under pmvivons of Chapter 9(commenting P
t� widsSection7")ofDividnn3ofdanBusinevmdProressiawCode.andmyit--1, 2 ILLMNTD WALL MTD SIGNS& 1 NONN-ILLMNTD BLADE
cern, infullfoncand
id,? ace occlass Lk.• SIGN
F p Oa¢ Comnnar
e ARCHITECTS DECLARATION
e¢ I undnvand my pima shall W used as public records
g u F- Licensed Professional
a03 OWNER-BUILDER DECLARATION
if I nrchy aRrm Nat 1 am exempt from the Ca^uuroh License Law for the
COO following reason.(Section 1031.5,Business and Prefconons Code:Any city or county
$ which requires a permit m emummt after.borrow.demmLsb,nr mPafr any awmurc
zi prior¢is issuance.also requires the applicant for such permit to file a signed surmount
<
that ImMiccnmdpmMmnuotoProvisions ofthe Contractor.LicenaeLaw(Chapter 9 Sq.Ft. Floor Area (- Valuation
Y1- (commend,with Section 7000)Of Division 3Ofthe Busiwvand Prof -medcode)w $10000
qy — that he ts uanpt Hterefrom m6 Ha bum for the alleged exemption.My violation of
Section 7031.5 by any,applicant for a permit subjects Hm applicant in a civil Penalty of OCC' anC Type
ot merroan fin hundred aalkrs(S50U 36940003 jW�tl�¢bei
❑I,u owner of Ne property,w my employees with urges u roe'--k compenadan,
will do thmwork,and the smtrerwG unmintd a
ender offendEnded.sak(Sec.7014,Buei
and PoIdeashmu Cadrun m conommrs Licessse es law doset apply to ad..,of Required Inspections
property who bui Ids w improvestherean,and who doessuch work himself or through his
own employer,provided Nmsech improvements menot intended oroffe ed fronds..a.
bwevrr,Hmbuilding bu1mPmvemmtuealdwithinYearofmmPmdan,daower-
builao will hart tea When of paving that um he ala wt Wild or improve for Purpose of
alk.). - ...-
1,u awxr of the Property.am ueluively contracting with licensed convectors b
murrocl the project(See 7014.Business and Proft m.Cade:)The Counselors U.
serer law does MI apply in an owner of Property who builds or improves themon,and.
who contracts for such pmjecm with a contracurr(s)licensed pursuant m the Conuactofs
Licen¢law.
O l am esemPt under Sec ,B d:P C fn,this
owner —Due Date
WORKERS COMPENSATION DECLARATION
I bereby aRam under penalty of perjury one of Ne following declarations:
1"On tuna will maintain•CerdOom of Consent m self-insure for Worker.Compcn-
-tion,u provided for by Sedan 37M of the LabOf Code.for the petforrom.of the
W
art for which this perveh is issued.
l7 1 ban and will maintain Workers Compemation Insuran¢,u required by Section
J]W of the labor Coda.for um performance Often,work for which this permit is issued.
My Workers Compe udon'p-rano c rtias and Polity moat er me:
Curter.. � Policy No.;
cEKnl`ILATE OF EXEMPTION FROMORKERW S'
COMPENSATION INSURANCE
(Thu wether need not keumpkmd ifft Permit Is fwono hundred dollars(5100)
or less)
I mrtiPo thnr in the Performance of the work for which this permit Is issued,I shaft not
employ any person in any reader ern,u b become subject in the Workers'Compereation
Laws of Calilomla.Dae
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become mbjecs in the Wohera Compensation,provisions of Ne Utter Cock.you muR
,J O
EfoMwimb comply wit such Frovius mor this permit shalt W ded
med toward.
Z� from
LENDING AGENCY
V; 1 hominy Nat Nem is a c mormetion lending agency for the performaue of
the work for which this permit in,issued(Sts.3097,Civ.C.)
Wh Q LsndCs m
Nae
z Lenders Address
U Q 1 mmffy,that I have mad Ws application and sum that the show information u
ty F Comm 1 agree m comply with all city and county amimucea and sum laws relating to
0 building construction,and bemby mmorine nprestoadvu or this city m enter upon the
-F yabon-mendarred property for imPeYaon puquses
(We)agree m-n,indemnify and keep harmless the City of Cupertino against
Vl liabilities,judgments,cuts and expmues which may in any way seeme Mutat-id City
U z in Co..,.of the grating of this Permit.
APPLICANT}1NDERSTAND$A WILL COMPLY WITH ALL NON-POINT Issued by:
... SOIIRC_FdVI.1T1GNS. // Y_91tafDate'? - 2��-
//^ij � �j/ P.! 7'Z-o cl- Re-roofs
Smgnvaum of Applr�ontrac or Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof �-
Will Hm applicant Or future Wilding oceupant stem whandle huardou material
as defined by the Cupertino Municipal Cade.Chapter 9.12,and Her Health and Safety
Crum.oy.tion 25532(a)? dN0 All roofs shall be inspected prior to any roofing material being installed.
Will the applic-tnrfuture Wilding Occupant use equipmmtordevices which If a roof is installed without first obtaining an inspection,I agree to remove
it Inwamous air conumiawu u defined by On Bay Area Air Quality MMMCTOcnm all new materials for inspection.
District?
❑Yes �No
1 ban mal the huaNuus ma enaumquirements under Chapler6.95 of Her Califor-
.iaHcuN&SectyC^do Soctiws 25M5.25533and 25534.1 otdcmund thaifHm building
Ja c0r 51>a�ee rtspouihilirY m notify the occupant of one
rt mire a me mum be met u' once tufa Ccnificam of Oct
°� °-y' Signature of Applicant Date
2 te
Owner car authorised agent Dam All roof coverings to be Class'1{"or better
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