04020004 CITY OF CUPIR'fINO 'mow
BUILDING DIVISION PERMIT CONTRACTOR+INFORMATION
r v63�r'*%Y',
DUI_DING ADDRESS: SIGN A RAMA PeRMITN'64020004
ER'S NAME: PERMIT ISSUE DATE
.ONE: SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDC ELECT' PLUMB MECII
woo LICENSED CONTRACTOR'S DECLARATION O O O O
y U C I hereby arum that I am IicenuO antler proyiVigns err Ch pier 9(commencing Job Description
5¢w withScct,�n'ByLjOLDivisionJofNCBdineva ssinnsCode.andmyliccnsis ��oo
i2Zin fallronaer r' SIGN- -COACH HOUSE LIQUORS
Licens''EElid LiC.a
�Fo Da¢ GVnlraCler . z :14 '1 .
ARCHITECTS DECLA ATI01 %.
I and nand y plans shall he used es public reenter MAR 2 : 2004
3 m t; Licensed Pmfessinnal
`Og OWNER-BUILDER DECLARATION
+'� y I hereby affirm that I am exempt from the Contractor's License Law for the ��BbB ®'p��
00 following mason.(Section 7031.5,Buss an
sined Professions CNC:Any city or county Ntl
Km which requires a pemtit m concoct.alter,improve,demolish.or repair any structure
prior to its issuance.also requires the applicant for such permit to file aligned statement
- < hat he is licensid pursuant to the provisions,Or the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
yH0 (commencing with Section 7000)of Division 3 or the Business and Professions Code)or
i $
that he is exempt therefrom and he basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of 3 SVTV940P ,'0 ane 0 Occupancy Type
not mom than five hundred dollars(5500). P Y YP
❑1,a sownerof the pmpeny, suis employed or
wages r their tele 0o 1.B stars
will domework.and Nehe Cocirnots LMcde,Law
Tresslepplytola,Bulinus
and Professions lCodedim mpr Conuactors rad who taw docs not apply to in owner is Required Inspections
propertywho buildsvi improveschevron,and who does inchwork himselfed roe sale.
his
own employed provided that such improvements in not i,mndW depletion,for owner.
builder,Nc building or improvement is sold within one year or completion,the owner
buil der will have the burden of proving Out he did not build or improae for purpose of
salt.).
❑1,as owner of the property,am exclusively contracting with licensed convectors m
consumer the project(Sec.I(Pa.Business and Professions Code:)The Contractor's U
cense law does not apply to an owner of ntt,mty who builds or improves meman,and
who contracts for such projects with a Contractors)licensed pursuant o the Comractors
License law.
❑1 am exempt under Sm .B&PC for this reason
r Data
WORKER'S COMPENSATION DECLARATION
1 hereby aRrm under penalty of perjury oro of the following declarations: -
„J I have and will maintain aCc rifidte of Conant to self-insute for Workci s Comp:n-
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as required by section
37M of the labor Code.for the performance of the work for which this permit is issued.
My Workers Cnm emalon Insurance carrier and Policy number am:
mer: r' Poli�
CERTIFICATE OF EKZMPTP3iVi FROM WORKERS'
COMPENSATION INSURANCE
(Mir secticap med not M complewd lime permil is form c hundrol dollars($100)
m less.)
1 eenify Nat in the p,rrom ince of the work for which this permit is issued,I shall not
employ any person in any manner ser as to become subject to the WorkersCompensation
Laws of California.Date
Applicant .
NOTICE TO APPLICANT:Ir,after making this Cenircate of Exemption,you should
become object m the Worker a ComNceni ion provisions of the labor Cask,you into t
z faMwith comply with such powism.or this permitshall be deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
F � I hereby aRrm Nat there is a comtrvetinn lending agency for the Performance of
ai 7 the work for which this permit is issued(Sce.3097.CN,C.)
(y Lender's Name
G
U Z Under's Address
I)Q 1 eenify Nn 1 have rad this application and sum that the above information retailing
is
It, E-'
It, hood m ding 1 agecomply with all city and county ordinances and sum laws relatingng re
p V holdingConstruction,pmpmly hcrebyaumon p rpmsenutives or this city to corer upon the
IJ.1 stove-(WC)a agree
pto save for emnify an keep ha
H G
(WC)agree to cove,indemnify and hick hay roan the City of Cupertino against y
h incoitid.jnea of thecoauang expenses which may in anyway accrvc againsLraid City
U z A APPLICANT
uRbegmmin,n his permit. ..
^' APPLICANT UNDE PA IDS AND WILL C MPLY W LL NONPOINT Issued by: Date
SOURCE REGUt.A
2111,04 Re-roofs
Signam fApplicin o'cun Date
ARDOUS MATE DISCLOSURE Type of Roof
Will the cam ser Tamm building accupam smrc or handle hadNous material
as definetl I �c Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
C.SecCY.25532(a)+ All roofs shall be inspected prior to any roofing material being installed.
1'/�}Q'
lj Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
et ha,ammr airmnstian tyu defined by the Bay Area Air Quality Management all new materials for inspection.
clYa
I have read the hnallous materials requirements under Chapter6.95 or the Califor-
niaHcalm&Safety Cmlc.Sccuons 25505,255 l and 25534.1 undersand thatitde building
tincts not curtentiy hove o tcapint,mat it is my espinslbilily m noufy the tacupsm of the
r}evimmenuw a mmMatutivu -come 'flea r c.pinerg ' Signature of plicant Date
Ownteas o 5ge rDille, All roof coverings to be Class "B"or better
CITY OP CUTER RENO
BUILDING DI VISION PLRD CONTRACTnR INFORM Nom:;
BUILDING ADDRESS: SIGN A RAMA PERMIT"0.4020004
ER'S NAME: PERMIT ISSUE DATE
PI10NE: SANITARY NO, CONTROL N0.
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
uoo LICENSED CONTRACTOR'S DECLARATION
Ym P 1 hereby arum that I am Ranted under prnyyaiipas of Chapter 9 mnmmeneing Job Description
eZw with Sec�Wo)of Division Sof NC Business audPbfeream,Code.evd my he...is
,t3y vomu, ander SIGN--COACH HOUSE LIQUORS
phi Liccnu Itis r Lic.p
o Dale o comma o
ARCHITECTS DE LLA ATR ION
y 04 a 1 uM9 slant my plant shall he.cJ as public aroNs
JyU
0, Licensed Pmfcssirnvl
`ar 1OWNER-BUILDER DECLARATION
a 5 w l hereby affirm that 1 am exempt from Ne Contianoh License Law for the
'0 following mason.(Section 7031.5.Business and Professions Cndc Any city or county
K ex Iki which requires a permit to contract,alter,improve,dcmalish,or repair any structure no
prior m in iuuoice.alsu recruit.NeaPPEcant rmairch permittu Ere a signedetamment
that he is licensed pammial ,the pm minas of Ne C.ramcURx License Law(Chapter 9 Sq.Ft. Floor Area ValUatlOn
st reommencingwith scniaamyl)nf Di,i,i..3nf N.Businessland Professions Code)or
a. _ tom he is e.cmpt therefrom and are basis far On,alleged exemption.Any violation of
Section?031.5 by any applicamfar a pcmrit subjccu the applicant I..civil pc..It,.f 36VRl461.be100 Occupancy Type
not moa Than Bw handled delta.(S500).
❑I,as owner of the property,or my employen with wages as their,aole corn sensation.
will do the work and the someum is not intended or offered for sale(See.206,1,Business
and Pmrusions Code:The Convenors License Law docs not apply to an owner of Required Inspections
property who builds or improves dimmon,and who doessuch work himself or through his
own employees,p ing or timsuehimprovementsin not ea:dedoff or mretired for owner,
builder .Ire building Orden of pmennissold within one year or completion.me owncn
builder will have rbc burden of proving Nm he did nm build or improv fur purses of
salt.).
I,as per of the Sec.7 y,.Business s and Profaning Cod:)seated eontrenors m
El 1. a the r of th(sec.moa, cnes and contrasting Code:)The d coni actor;Li-
came Law docs not apply to an owner or property who builds or improves Water,and. l ��
who contracts for such pockets with a eonvacuor(s)licensed pursuant to the Conuacfors v
License Law. eJv/
I am exempt under Sec. .B&P C fur this reason /
wncr Data
WORKER COMPENSATION DECLARATION
I hereby affirm under penalty or perjury one of the following declarations:
❑rhaw amt rail for
eCcnl3am of Consentm Clude.sum forWmkcrs C.of the
tanto,as provided for by Section 1100 of the Tabor Code for the pcNormana of Nc
work for which this permit is issued.
❑1 have and will maintain Wmkcrs Compensation Insurance,as requited by Section
37f1B of NC Labor Code,for due performance of the work for which this permit is issued.
My Worker's Com <ni I Insurance carrier and Policy number art:
mer. '�" �2 Poli
CERT( R6Ak O EX PIT=OM WORKERS'
COMPENSATION INSURANCE
(Thu section recd art he completed if the permit is forone hundred dollars(SIM)
or I.a)
I ccnlry Nm in the Pcrfommnce of Nc walk for which this permit is issued.1 shall not
employ any fiction in any manner an u to become subject m the WorkersCompensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenificam of Exemption,you should
become subject a he Workcis Compensation previsions of the Larval Cade,you muse
Z forthwith comply with such provisions to this permit shall be deemed m idmd.
z O CONSTRUCTION LENDING AGENCY
E- 2 Ihcndall.Brm Nat date ism construction Ending agency fm ft performance of -
G' ? Ne work for which this s.an'd is issued(Sec.3041,Civ.C.)
W (] Lender's Name
7 Z Lender's Add.
U O 1 certify that 1 have read this application and sum that the above information is
ly F correct.1 agree to comply with all city and county ordinances and sum laws reining to
pU building eonswction,and hereby auNoris mprcaenutivw of this city to enter upon rbc
G
shove Mentioned property for impcairn purposes.
(~ (We).,me to save,indemnify and keep harmless he City of Cupertino against l
N
liabilities,judgments.costs and expenses which may in anyway aceme against said Cly
UZ inconuqucnccrf NcgramingoIIn permit.
^ APPLICANT UNDERSITND$AND WILL CtSMPLY W LL NON-POINT Issued b9 DaIC
SOURCE RICGULA 16N5� /�j// / y
�� � / /I
/ 5r �
Re-roofs
Sign wr fAPPhcaMC-tenor Data
/qAkLARDOUs MATER.A DISCLOSURE 7� T_ Type of Roof
Will Ncapplicam or Boort building wcupant sImc or handl.hUrald0as material
as defined ha i Cupertino Municipal Code.Chapter 9.12,and the[health ant Safety
Crude
,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant rrfuture rbuilding mention Use e4aipmentordevices which If a roof is installed without first obtaining an inspection,I agree to remove
mit bvradow art eoommirci nLa,u defined by he Bay Arca Air Quality Mawgemcnt all new materials for inspection.
District?
❑Ycs
I have mail the hmardoax materials aquircmcnts under Chapter 695 of the Califon
ma HeirlN&Safety Code,Secdmu 255n5,355 1.025534.1 t ndentand Nat if the building
does not Cumcndy have a xca6m Nat it u my csponsibility,m notify Re Occupant of the /
rinuiam.na whje�sube test prior rr itsv enrac Signature of plicant Date
Owner arau err;. =g. D7._
All roof coverings to be Class"B" or better
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-- • CITY OF CUPERTINI
SIGNCITYOF
oa
CUPEkTINO PERMIT APPLICATION FORM
APN # / Date:// 0
b / Date:
Building Address: O
Owner's Name: Phone#:
&aco 24-2-
Contractor: License#: •�/Z�/ 3
Contact: Phone#:
Applicant/Contractor:
uildin ermit Info:
Bld Elect Plumb Mech
Job scription:
sidential: Commercial: (�vi}(rC
Sq.Ft. Floor Area: EiA
�O D• Architect/Engineer:
SCLL�Type of Construction:
1-7 /
if
tftlicble Fee ID Fee Description Fee Group
ENERGY 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 Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG