04050021 CITY OF CUPFRTINO 2e^ s seas.t' a
BUILDING DIVISION PERMIT aCONTRA.CTQRINFORMATION
BUILDING ADDRESS, PERMIT Nb 4 0 5 0 0 21
2
NAME: PERMIT ISSUE DATE
STAR VIDEO
ONE:
SANITARY NO, CONTROL NO.
ARCHITECg/ENGINEER: BUILDING PERMIT INFO
BLDG EIECf PLUMB MECH
LOQ LICENSED CONTRACTOR'S DECLARATION ) b Description
ua 1 Wmby affirm am
that I licensed under ptocom
virlons of Chapter 9( mo
encing
i wide Sution J011B),roivision3afthc Bri and Proressimuc aMns
er'Im eis
"`o rat mmn roree dApt(me _ V �. SIGN--2 ILLUMINATED CHANNEL L;��� �
i Dam�s�a6f Ll.p
^� Dam comacmr CONTRACTOR: ACTIVE SIGN
RCHITE r�Sy DECL}�ARA ON
w< nd��m�9"h iJi `mow MAY 26 2004
,�S Liccvcd�CWl ssimmay
OW R-BUILDE DECLARATION MOLDING I hereby affirm that 1 am exempt from the Commelofa License Law far the IYJ����utl�
�QO following maso.(section 7031.5.Business and Professions Cade:Any city or county IV) t� NG
g E which requires a Permit to unstmeL alcor,improve.demolish.or motor any stmcmm
FIy prior to its issuinm,abu raquirrs 1W.P11icant forsueb permit to file a signed statement
< tion of _T
that W is licensed pursuant tht provisions,of J¢Conosctufilaense Law(Chapter 9 Sq.Ft. Floor Area Valua�ytglg00
¢Fa (commencing with Section 7000)of Division 3 of NC Business and Professions Code)or
the bulk
tion.Any
Section 7031.5 by my applicant W is exempt t1somfireen t for a permit subjects the applir the alleged! cant to a rnillPenaltY of
not mom man five hundred dollars/3500). APN Number Occupancy Type
r.as mvnm mrlW m 32607020 . 00
❑ t stractaf mycmplonmes wimwagesumle(ante cmopewness
will do the work and the he Com is not intended m oar do footle(Sec.in an,Busweer of
and Professions Cade:The Cantracmr]License law oats rwt.poly m an awns of Required Inspections
property who buiIdaofireproves mmean.a id whodocasuch work him elfcar domain his
Own employ=,provided mmsuch improvements are not intended or offered forsam.If,
hawews,me building Or improvement is sold within arc year of smmpleuon.the owner-
builder will haw me burden of proving mat he did not Wild or improv far purpose of
sale.).
❑1,as owner of me propeny,am exclusively contracting with licensed contnnom to
..net the project(Sec.load,Business and Professions Cade:)The Contractm'a Li-
unee law dors not apply in an mover of propany who Wilds or impmws mcman.and
who tomato for such projeeu with a contracmrud licensed pursuant to the Comnnor's
Lkcrom Law.
Iamexemplummo Sea ,B&PCforthismmcm
er Data
WORKER'S COMPENSATION DECLARATION
1 hereby afrion under Penalty of perjury one of the following declarations:
1 hew and will maintain a CcniOcam oConsent ure
f Conseno aelf-insfor Warkeb Comte
pe
cation.as provided fm by Sadao 3700 of dm IaWr Code.far the performance of the
work for which this permit is issued.
❑I bw and will maintain Worker's Compensation I ce,as required by SeNon
3700 of the labor Code.for me pcf..kxce of me:o�hick this permit is issued.
My Worker's Car ssdon lnsumnua 'u end Pali Wr am:
artier. `� Polity No.. C —
CERTIFICATEOFE% PION FROM WORKERS'
COMPENSATION INSURANCE
(This aoc0on need not W completed Rthe pmanh is for onchundred dollars($100)
or less.)
1 unify that in the performance of the work for which this Permit is issued,l shall nut
employ any Person in any manner so as an bceomt subject to the Workar5'Compereaden
Laws of Califamia.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ccififtcam of Exemption,you should
become subjectto the Worker's Compensation provisions of the IoW!Cndc,you must
.J,7, foMwim comply with such provissmu or this Permit shall W deemed mwked.
ZO CONSTRUCTION LENDING AGENCY
(-.52 Thereby alarm dust mem us construction lending agency for the Performance of
[�7 me work(tar which this permit is issued(Sec.3197,Ci,C.)
Ig1 Lenamrs Name
G Iandeis Addmu
U C) 1 certify that 1 have read this application and sum that the above information is /
(—' cmmct.I agree to comply with all city and county ordinances and state laws totaling in
OU building construction,and hereby tathorim mpmmnmtiws of this city to enter upon me
W aWw-menliarmd prapeny for inspection purposes.
L}, (Wa)agree to saw.indemnify and keep harmless the City of Cupcnino against
liabiliun,judgmenu,costs and expenses which may In my way accme against said City
U Z in consequence of the grammg of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH NT Issued by: Date
SOUR RTG LATIONS.
i1 ltd 1�`� roofs
Si of Appli vacmr Data
N ARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant of future building ucup nt store or handle hemrdous material
fined by me Cupertino Ybullding
Cndc.Chapter 9.11.and the Heaton and Safety
.S=edan 3.5531(')7 All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant to occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil im Mous air conuminanB u&fired by lW Bay Am.Air Quality Management all new materials for inspection.
Dinrict7
❑Ycs N
I haw .)the hvardtu rialsreyviremcnu unJcr Ch ter6.9 of me Gli(ao-
niaHalm&Sad ode. uns35.R)5.25533and2553a.lunders tktifdm Wilding
.)ors mol cu y haw l tenant,that it u my mspomihility m notary IW aeupent of me /
rcqui swhichmunW I darwissaanceoracerdfiateoraupmer. Signature ofApplican[ Date V
v All roof coverings to be Class "B" or better
Owner-or amhori' cog t Da¢
CITY OF CUPERTINO
BUILDING DIVISION PERMO 4CONTRACTORlINFORMr,
BUILDING ADDRESS: PERMIT Nfb 4 0 5 0 0 21
2102 U
ER'S NAME: PERMIT ISSUE DATE
STAR VIDEO
Pf{ONE:
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
X00 LICENSED CONTRACTOR'S DECLARATION
w 1 hereby firm that 1 am licensed under provisions of Chapter 9(commencing Job Description
i with Secdon7IX10)of Division 3 of the Business and Professions CWC.md my license is
^ ci in ruse tome Lace — �/ v yhny� SIGN--2 ILLUMINATED CHANNEL LETTER
5 g 2 Liccntt CI "— Lia.N
�-o Date 0Convactor CONTRACTOR: ACTIVE SIGN
Yf RCHITE S DECLAR'4001L
Y I andcrsh Of pl .hail he us a <rtrnrdr /
7 eco l/ / Ls✓�� �i
`LL Licensed lona fJ�E/
cS OW on CXCMDE DECLARATION
y I hereby.(firm u m I em exempt from the Coronal Chs License Lew for the
p 0 followhich pe mason.a Permit
t 703 LS.Business Professional Chic:Anyrepair
a y m counre O
K$� which myuims a pcmit w cnnswc4 alter,imprnvc,demolish,nr repair any xvucwhe
v prior to its issuance,also re,.j.tk applieam ftn etch permit topic a sigacd sulcmcm
that he is licensed pursuantto she provisions of the Contractor'sLimmen Law(Chapter9 Sq.Ft. Floor Area Valu X00
is- (Commenring with Sertioa]0007af Divlxion3 at Bushne sod Pm(cenGadC)m
i .. that he U exempt thcrtfmm and the basis for fie alleged exemption.Any violation rf
Section 7031.5 by any applicant fon permit subjects the apPlicmt m e civil Penalty of APN Number Occupancy Type
not mart then live hundred dollars SIM). 32607020 . 00
❑6 u re work,the framochur my o,manses with wages u dnv(Sec.
compcn sins,
will do the work and theswctumisnuti Lt. Lswddfor salepply.toso Business
and Prty who
CWc:The cnnmerco,and
Law doe.not apply lf an uwam is Required Inspections
Own enyloy buildsoded that such imprandwbo meet doessuch work oroffre for Weugh his
employers,provided prsuchimprovementsin not intendedmpleded for sale.If.
bull&, 01 buildingorimprovement issoldwithin one year of completion,the oose of
builder wiB have We burden of proving that he tlitl not build or improve far purpose of
seta.).
❑1,as owner of the progeny,am.elusively contracting with licensed Conwetors to
construct Ne projee(Sec.7061.Business and Profusions Code)The Contractor's Li-
cease Law does not apply to an owner of property who Wilda or improves thereon,and
who convects for such projects with a comnetor(s)licensed pursuant to Be Contractols
License law.
I am exempt under Sec .B&P C for this mason
Date
WORKER'S COMPENSATION DECLARATION
I healthy aflina under Penalty of perjury one Of the following decleratiang
Cl I have and will mainmin r Ccnifcale of Cm6Cnl to self insure for Worerr'sCompm-
Wion,as provided for by Section 37W of We Labor Cale,for the reffirmance of the
work ter whim this Permit is issued.
❑1 have and will maintain Worka'a campensasion Insu nce,as mquirtd by Scedon
3]00 of the Labor Cade,for the peformanec of the wenWhich this permit is issue&
My Worker's Compensation Insurance Ccayrricnad Poli her arc: s
asri<r.� I& �Xh Polity Nto..
CERTIFICATEOPSATIONI NFROM WORKERS'
COMPENSATION INSURANCE
(Thissecdm need not W completed if the permit Is for onehunda d dallvrs(SIM)
m 1csa.)
I ced(y fast in the Performance of We work for which this Permit is issued.l dull not
employ any Person in any manner so as to become subject to theWorkers'Compensation
• Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenibeam of Exemption,you should
become subject as the Worker's Compensation provisions of the Labor Code.you mug
,a 2 forthwith comply with such provisions or this Permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(-. 1hereby Tom that done I..consvuctinn lending agency fur the perrurmance of
ai> We work for which this Permit is issued(Sec.3097.Civ.C.)
If]Q Lander':Name
z Lenders Address
U C) I certify that I have head this applicaum.and sum that the aWse information If / s
I2.f—' cored I agree to comply with all city and county DNinances and state laws misting to
0 building eonarr ion.and hereby amhariae rapmaenudvca of this city to crier upon We
above-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep humlcss the City of Chinni..against
C.
liabilities.judgments.costs and expenses which may in any way assn against said City
U Z in ei mseq.mcc of the&ranting of this Permit.
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH:ALtfIONPOINT Issued by: Date
SOURQE RFrGVLATIONS. !�a//�—
/�C/! S- 11 -roofs
Sigh of APPli nwctor Data
I{p gBOGUS MATERIALS DISCLOSURE Type of Roof
Will We applicant or future building Occupant store or handle hazardous material
as defined by the Cupertino Munici I Code.Chapter 9.12,and the He.IN and Safety
e.secdar 25532(.)] All roofs shall be inspected prior to any roofing material being installed.
❑Yes ]
Will We applicant or atom Wining arnywnt use ewipmrnt or devmex whim If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdnus sir cmunniom.as dcnncd by the Bay Arca Air Quality Management all new materials for inspection.
District]
❑Yes N
I have mmWWl//IWchavardous mrialsmquimmcnuunJ,Cha .,69ofNcCaliror-
niaHell%&srif ode,Sec onsM505,25533md]5536.Imdkrm Gd Natif Nc Wilding
doesnotcurt tyhumamnMLthatitumyrtspomibilitymnodfythe=UPWLof We
require .wnimmost x t nortoissuanceof.cerureamofOcupaney. Signature of Applicant Date
T I? All roof coverings to be Class"B"or better
Owner-or authod7A ag t Dam
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• CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 32607020 . 00
DATE ISSUED. . . . . . . : 05/04/2004
RECEIPT #. . . . . . . . . : 25427
REFERENCE ID # . . . : 04050021
SITE ADDRESS . . . . . : 21020 HOMESTEAD RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : STAR VIDEO
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
RECEIVED FROM . . . . : ACTIVE SIGN CO.
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
• TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- -------- ----- ---------- ---------- -- -------- ------ ---- ----- - ----
BPERMFEE VALUATION 2 , 800 . 00 77 . 00 0 . 00 77 . 00 0 . 00
BPLANCHK PERMIT FEE 77 . 00 65 . 45 0 . 00 65 . 45 0 . 00
BENERGY PERMIT FEE 77 . 00 23 . 10 0 . 00 23 . 10 0 . 00
BREMSIGNAD NO. CIRCUITS 1 . 00 4 . 44 0 . 00 4 .44 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BREMSIGNS NO SIGNS/MARQ 1 . 00 22 . 20 0 . 00 22 . 20 0 . 00
BSEISMICOM VALUATION 2 , 800 . 00 0 . 63 0 . 00 0 . 63 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
---------- ---------- -- -------- - -------- -
TOTAL PERMIT 328 . 34 0 . 00 328 . 34 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----- - ----------- ------------ ------------------
CHECK 328 . 34 1439
TOTAL RECEIPT 328 . 34
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
----------------------------
101 FOUNDATION 103 UFER
104 REBAR 105 ANCHOR BOLTS
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
514 FINAL PUBLIC WORKS
•
r
CITY OF CUPERTINO 6 Js,6 D '2-1
SIGN
•CUPEkTINO PERMIT APPLICATIWFORM
APN# Z6/ Date:
3 o.Za oS
Building Address:
z/oza
Owner's Name: S-*R Vlpz—o l\ Phone#:gZ _ 49_ 7N�
Contractor: � n License#6���/
Contact: J Phone#:
Applicant/Contractor:
Building Permit Info:
Bldg a Plumb Mech
Job Description:
Residential: Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
Qty. if
4plicable Fee ID Fee Description Fee Group
IZI BENERGY Energy BUILIDNG
-11PERMFEE Bldg Permit Fees BUILIDNG
BPL CHK Plan Check Fee BUILIDNG
S SMICOM Seismic Commercial BUILIDNG
EPERMII'FEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG
f '�