05050093 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR�INFORMATION
BUIL DING ADDRESS: ACTIVE SIGN CO PERMITN 05050093
W NER'S NAME: PERMIT ISSUE DATE
NE: SANITARY 0. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELER PLUMB MECH
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LICENSED CONTRACTOR'SDECLARATION 1{� ���® O
>;U I hcmby affirm that 1 am licentedCONTRACTORS
under S DECoes AChapter 9(commencing
Job DescriptlOpU_y
<i with SmxLkm700ffi.f Divisiom3ofO Busines and Proffssinn Code,endmylicuscis
�h in full force and effect, s,
gqI LiccnacCloss W Lic.M SIGN--2 SETS WALL SING
Dam Contractor
ARCHITECTS DECLARATION 2005
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I undersandu my plans shall W amid public recordss!T L J
JyU
Limrscd Pmfcsxional � gt I tt ®�
OWNER-BUILDER DECLARATION hyYlpt Itpl�
.�<M 1 hereby affirm Nal I am exempt form th,Contractor'sLicense Law for the
_O Ofollowing memo.(Section]f13 L5,Business and Professio s Cook:Any city or county
99 which requires a Permit to construct.alter.improve,demolish,or mpair any avucture
prior bac its issuance,abo mquies the applicant for such Permit to file a signed so mment
t�< that he is licensed pursuant the provisions of the Common's License Law 9 Sq.FL Floor Area Valuation
tt
an--O (commencing with Section 7M))of Division 3 of the Business and Professions Code)or
y
Out he I,exempt tincrefrom and on,base for the alleged exemption.Any violation of troy p.y ra,w,k,
Section 7031.3 by any appliantfar apnmit subjects dmapplkan to Advil penalty of 32V14n0Y0iroO Occupancy Type
not mom Nan five hundred dollars(5500).
[]h ss owner of the progeny,or my employees with wages u their tele compensation.
will do the work,and the structure is not intended or offered for sale(Sec.7064,Business
and Profevitns Code:no Contractors License Law does not apply to an owner of Required Inspections
Properly who builds or improves sereno,and who does such work himself or uhrough his
own employers,provided Nat such improvements arc not intended or offered re rsale,If.
however,line building or impmvement is mid within one year of completion.the owner-
builder will have the burden of proving Nat he did not Wild or improv for purpose of
.to I.
❑1,as owner of the pmpcny,am exclusively contracting with licensed contractors to
convect Ne project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense law does not apply 0 an owner of property who Wilds or improves thereon.and
who contracts for such projects with a eoevacorKs)licensed pursuant to the Convectors
Lead.Law.
❑ I am exempt antler Sec. BAr PC far this ressim _
137Wrom Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following aeclaradons:
have and will maintain a Cenificae of Consent to self-insure for WorloersComPen-
n,ss provided for by Section 3]00 of the Labor Cade,for the performance of the
for which this permit is issued.
have and will maintain Workers Compensation lnsurmcc,u required by Section
of are Labor Code,for the performance of the work for which Nis permit is issued.
Workers Compensmum lnsumnce Mel tend Policy num om e:er: Policy No.: lG4ili;,,,
TIFICATE OF EXEMPTION FROMORW KERS'
COMPENSATION INSURANCE
Mir section need not W completed if the permit is for one hundred dollars($10!0
of leas.)
I certify Nat in the performance of the work for which this Permit A issued.I shall not
employ any Person in any manner an u to Antonio aubjeeuo the Worlams Compemadon
Laws of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenifmcam of Exemption,you should
become subject in the Worker's Compensation provisions of the Labor Code,you mus
.J O foMwitb comply with much provisions of this Permit shall bo deemed revoked.
Z'Vy CONSTRUCTION LENDING AGENCY
[r I hereby affirm Our then is a convection lending agency for the parrorm.a of
a the work for which this permit is issued(See.309],Civ.C.)
W A Leadcr's Name
,=Z Landers Address _
U 0 1 unity Nat I have mad this application and sac e Nat On above information is
W E' correct I agree to comply with all city and county on inanas and some laws miming to
O V building convection,and hereby.thorie mpresenotives of this city to enter upon the
r W above-mentioned property for insp etion purposes
G (W,)agree to save,indemnify and keep harmless the City of Cupcnino against
F" h liabilities.judgments.toss and expcascs which may in any way accrue against said City
V Z in consequence of the granting of this Permit.
^ APPLICANr UNDERSTANDS AN WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR-'�nREGULATIONS. /
4&? r1/i✓l v oS/�//��4 Re-roofs
Si escort ppli artCont for Date
H47 to Data
Type of Roof
Will the applicant or future Wilding Occupant mom or handle lsrardous mau:rial
As defirmd by the Capetian Municipal Coat.Chapter 9.11,and the Health and Safety
ode.Scaion 15532(a)? All roofs shall be inspected prior to an roofing material beim
❑Yea P P Y g g installed.
Will the applicant or future building rccupanruse equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
it hauAnus air contaminants As defined by the Bay Arta Air Quality Management all new materials for inspection.
District]
❑Yes gPu
I have mail the hmarth nds 25505.25533
55 5.255 3 and2 5 under Chapterd thou true,
Califon-
nuHalth&Smaiy Cndc,ScNis materials req y.d tits un 1 r6.95 iDM Wilding
does not currently hoe a tent N t a d,my responsibility m nndfy the as.,Or the
coq 'rt I Itch muI our r wissu.ce.r.Cmiilica.0l0cca cy. SignatuofApplicant Date
�)
owner. thm;.caas, i D,e All roof coverings to be Class"B"or better