02120059 CITY OF CUPERTINO - -
BUILDING DIVISION PERMIT CONTRACTOR IN4ORMATION a
I"DING ADDRESS: PELICAN YSIGN SERVICE INC PERMITNO.
0420 S DE ANZA BLVD # C
NER'S NAME: 1565 LAFAYETTE ST APPLICATION SUB DATE
HUNTER PROPERTIES 12Z13/2002
HONE: (408) 246-3833 SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: - BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
]K Q 0
u0o LICENSED CONTRACTOR'S DECLARATION
1 hereby M.that I am licensed under previsions of Chapter 9(commencing Job Description
n< n'ithSectio,T )Qooff Divisio 3NdABusircupd Profcviom Code.and my license It ���p (J� ��®
ucenlseCue `- rib 9vL Lk.Y✓J G 8'U SIGN 9 Vtl!'i"�l
7 Ost Das ? cut
ACT'D A
iI uiMersune my plans mail he urea ubic mcords APR 10 2003
"r�
Licensed Professional BUILDING
OW NERBUILDER DECLARATION
i<2 I hereby afbnn mu I am exempt,(rem the Convenors License law for she
i 0 O following reason.(section 7031.5.Business and Professions Code:Any city or county
5$ which requires•prm,it to cnnmuc,.alter,improve,demolish,or repair any suuctum
-ty prior b its issuance also sequins the Applicant for such permit to file a signed statement
ii a thatMislicensedpursuammMeprovisiwofdcContrxsmilticemclnw(Chapter9 Sq.Ft.Floor Area $25'40tion
y (commencing with Section 7")M Division J or the B usinev and Professions Code)or
$ Nat he IS exempt therefrom AM the basial fm the Jle SA evmption Any violation of
Section 7031.3 by any applicant for a permit mbjecu Site Applicator to a civil penalty of
not more thm five hundred dollars(ISM be Occupancy Type
1,v owner of dx prepeny,or my cmploycu with wgu u their role comprnvtion,
will do the work.and Ne mucture is not intended reoffered four sak(SN.7014,Imunev
atsd Professions;Coda:The Contractors License taw does net apply b an owner of 103 - UFER eyed Inspections
prepe xt who ba ilN mimprov thereon,•M wood.suchwork himxlfor through his
own employees,provided that such improvements ere not intended oroRered for We.If. 104 - REBAR
hmcwr.the Wilding or improvement is,Sold within one year of completion.the owner-
WilderwiBhavedcWrdenorprovingwlhedidhotWildorimproveI.,purposeof 105 - ANCHOR BOLTS
"k')' 304 - ROUGH ELECTRICAL
01,As owner of the property,am exclusively contracting with licensed contractors to 505 - FINAL ELECTRICAL
construct the pmjec,(Sec 7044.Business AM Prefeuions Code:)The Contractors U.
eeme law deal not apply to an owner of property who holds or improve;thereon.and 514 — FINAL PUBLIC WORKS
who contracts for such projects with A eneva"or(s)licensed pursuant b the Convectors
rue law.
Am exempt under See ,B6:P C for this rruon
net Date
WORKER'S COMPENSATION DECLARATION
1 hereby album under penalty of p"jury once of the following dcdMations:
0 I have and will maintain a Cribfi seof consent he asirinsure for WorkersCompen-
vtion,AS provided for by Section 7700 of die labor Code,for the perfoumance of the
work for which this permit is issued.
❑I haw and will maintain Workers Compensation Insurvtee,v required by Section
7700 of the labor Code,for the prrformanee of rib work fm which this Permit is issued.
My Worker's Compensation In..cagier and Policy number ere:
Tye
k./ CERTIFICATE OF EK EMPfIPntOI .601 WORKERS'
COMPENSATION INSURANCE
(Thu mcrim need WIN completed if dr Permitil me one hundNd dollar(SIW)
or tui.)
1 Nitrify the,in the performance of the work for which Nis Permit is issued.I mill not r
employ any person in any mmnerso AS le become subject b the WorkerCompensation
laws of California.DAN
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Eacmption,you mouW
become Subic"tithe Workers Compemation Provisions of eta labor Code,you mum
zOforthwith comply with such Provisions"this permit dull be deemed revoked. .Y
CONSTRUCTION LENDING AGENCY
r
(-� I W r which it on permert is a ed(See 3W7an . agency for NC Performance of
ai 7 Le work for which this perm;,I.issued($ec.709],Co,Civ.CJ
z lander;Name
7 z Iandcra Address
U C) 1 certify Nat I haw read this application and auto Nu the above information is
DL f•' CenecL l agree in comply with all city and county ordinances andaute I...)sun,1.
O V Wilding construction,and hereby mthorin representatives of Nis city to enter upon the
{Ll ahove-menrionedpmpeny for inspection phichma
4 (We)agree to Saw,indemnify and keep hmnlev the City of Cupertino against
r/J I.coitiuuorace emu,costs And expenses which may in any wry accrue again,vid City
t1z in covegucntt of dm nnung orris Areumit
a SOURCE APPLICANT U NTS NDS AND WILL CO PLY WI ALL NO—OINT Issued by: Dale
Applican onvactor Date, Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will
II the applicant or furore Wilding Occupant store or handle hautreous material
deftncd by the Cupertino Municipal Cade,Chapter 9.13,AM the Huhh and safety
We.section 25552(.)]
❑Y AnAll roofs shall be inspected prior to any roofing material being installed,
Will the applicant m future Wilding occupant um equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
emit haurdbous air contaminants AS defined by the Bay Arta Air Quality Management
Disui"] all new materials for inspection.
❑Yu
I have read ds havNnu mncrials uequncona uM&rChupter6.95ortheCalifor-
maHealthkSafety Code,Sections x5505,3557)and x5574.1 undcusund that if ted Wilding
doe;net comeney he Lthat it rimy resPo iWityb one Occupant of the
requiho e c ie me,prior b ism a Ccru He of pan y.
Signature of Applicant Date
CITY OF CUPERTINO D 1 ( 2- 0--0 S
SIGN
• CUPEKTINO PERMIT APPLICATION FORM
APN# Date:
Building Address:
/o y26 - S. 6e17ti31L 61..J
Owner's
�-
Owner's Nam�e)- 11 (� Phone#: so r
Contractor: License#:
Pa r) S� ,� -rervjc.e T� jr. e6h9y3�90 5/d,0
Contact: / Phone#:
Applicant/Contractor: 11 o t"
g Permit Info:
B 'dg Plumb Mech
escription:
Residential:- Commercial:
Sq.Ft. Floor Area: $/Sq,Ft.:
• Architect/Engineer: Valuation:
7J , y —
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee.Grou
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Sings, Maz uee ELECTRICAL
BUSLIC Business License BUILIDNG
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