04030218 CITY OF CUPERTINO ,
BUILDING DIVISION PERMIT 3CONTRACTOR INFORM- ON
GUIDING ADDRESS: ARROW SIGN CO PERMIT N004030Z18
ER'S NAME: PERMIT ISSUE DATE
HEWLETT
PHONE: SANITARY NO. CONTROL NO.
(510) 533-7693
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG O PLUMB MOECH
ZO LICENSED CONTRACTOR'S DECLARATION Job Description
1 bcseb,affirm that 1 am limnsed under Pleuritic.of Chapter 9(commeming P
rttj with Section 70(9))or Division 3af rite Burnwand Profession.Code,and my Its...is
AN< ; m fait roes anderrecL SIGN--2 ILLUM MONUMENT
R License Clw LkJ
L- Dem Cunoaclar
ARCNITECrS DECLSRAT
3 LL U I underiunJ my phv ahN he used u public recnNa .
�O Lkcvcd Professional
OWNER-BUILDER DECLARATION
MI hereby alum that I am exempt focus the Com acmes License Law for the
fallowing resson.sauun 7031.3,Business and Pm(euiou Code:Anychyor county
a which requires a permit m construct.alter.improve,demolish,or repair any structure
v,zy prior to its issuance.also requires the applicant for such Permit o Ole asigned statement onn
< mat hehliceveJpursuantmthcpmvisiovofthcConmcmrSllamelaw(Chapta9 Sq.Ft. Floor Area Valuation
(commencing with Section 7000)of Division 3 of the Bummeaond Pocfwinns Code)or
Nu he is exempt merefrro and the bash for the alleged ea unishm Any violation of
Section 703 LS by arty applicant far a permit subjects the applicant to a civil penalty of 31�616il"crO 0 Occas ane e
not mom than to.handled dollars(M). P y TYP
❑1,as owner of Ne Property,or my emplayeu with watts a mehsole eouspenssden,
will do the work and Nesuuctuu is l o btumded oroffered forsale(Sec.7010,Business
and Pmfussiam Code:The Committees Lt..law don not apply to in owner of Required Inspections
property who Wilds or i m proves thereon,and who dans such wmk himseif or INnugh his
own employcn,provided that such improvemenH are not Intended aro@real formals.IL
however,the building or improvement is sold within one year of compledon.Ne owner.
Wilder will move ft burden of proving that he did out Wild or Improve for purluse of
talc.).
❑1,as owrcr of the property,sum exclusively eorsuting with licensed conmaclM to
construes the project(Sec.7014,Business and Profession Code:)The Carmichael U. '
cove law don not apply to an owner of property who builds or improves thereon,and
who contracts for such pmjecu with a contractor(s)licensed pursuant to me Cnmaetoes .
License Use.
❑I me exempt under Sec. ,B h PC for this lesson
Data
Per WORKER'S COMPENSATION DECLARATION ^1 1
I hereby affirm under penalty of perjury mut of the ratio)Jr—g declarations: t
f f \.
❑Thaw and will for
eCen 3700 of ft som to LabrCode.furerorerform Camperse
ashen,r provided for by Section 3700 of rix labor Code,f the perform-7 the
work for which Of,permit is issued. ` 1[r1
❑1 have and will maintain Worke's Compensation Insurance,u required by Secti 11+)J
3700 of the Labor Cade,for the performance ofthe work for which this permit is Issued. U'
My Worit es Compenssdon iv urriu and Policy number are: EDi
Carrier.__ FWA PolityNa.:`y"1G-03 I.U^nd
CERTIFICATE OF EXEMPTION FROM WORKERS'omn5
COMPENSATION INSURANCE
fnrhsecdon toad nm beeampleted lfthe permit h foram hundred dollars(SIW)
or teas.)
1 calcify that in the performance of me work for which this Permit is issued,)shall not
employ any person in any manmr so sob become subject to the Workers'Compcmetion
Laws of Califomis.Dau
Applicant
NOTICE TO APPLICANT:If.after making this Ceniftnia or Exemption,you should
become subject to the,Worker's Compenution previsions of the labor Code,you mum
0 0 forthwith comply with such provisions or this Permit shall he deemed revoked.
Z"r CONSTRUCTION LENDING AGENCY
ti
F hereby whichI(Burndo that drum iia rovtmc.30 lendin{agency for tite Performance of
C' me wort for which Nis permit 4 issued(Sec.J097,Co,C.)
aQ Lndcea Name
=z I<nderi Address
V 0 1 unify that 1 have read this application and arc that the above information is
{T.U camecL 1 Agra to comply with all city and county ordinances and lint,lave relating In
0 Wilding construction.and herebyaumorise mpresentatiwa of this city m eras upon the
W shovememioned property for inspection purpML
py (We)agree so save,indemnify and kap hamOw the City of Cupenim against
,A liabilities.judgmcnu.cosm and ease.which may in any way accrue agaiw said City
V t�7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE��ii�yL�ATI . 3 * —
l JU(aAn qj_ 3 to/' Re-roofs
Signature ofApplicasuCormacter
HAZARDOUS MATERIALS DISCLOSURE — Type of Roof
Wit mo applicant or fumm Wilding occupantsmre or handle huaadoua material
u defined by the Cupertino Municipal Code.Chapter 9.12,and the Hulth and Safety
40 e,Section 25532(.)?
0y. X NoAll roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant rat equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
emit haxardnus air comaminanu as de0ncd by the Bay Area Air Quality Management all new materials for inspection.
District?
0Yes �No
I have mad the haummrr materials requirements under Chapter6.95 of the Califor.
nia Hcalm&Safety Cad.Satiou 253(15,25533 and 25534.1 undcreund matif tfr Wilding
don not currently how a unarm,Not it h my nnperemnitty In,wtify the aeupant of she
requirements which mmerpriarmiasm aaraceeirnto rasp ,y. / Signature of Applicant Date
� 1
Owner ser aumorioctl agent Dam All roof coverings to be Class "B" or better