08080101 CITY OF CUPERTINO
BUILDING DIVISIONPE MET = CUN iACTQit IN'l'( , A'TI(JPT""w:'.
BUILDING ADDRESS: pERMff N0.
10885 N STELLING RD PIERCE SIGNS & DISPLAYS, 08080101
NER'S NAME: PERMn'L%UE DATE
"\ A1,I�1' CHURCH OF SANTA CLARA 307 MERIDIAN AVE 08/14/2008
PHONE: (408) 292-3500 SANITARY NO. CONTROL NO.
ARCHI7EC(ENGINEER: BUILDING PERMIT INFO
BLDG EI.ECI PLUMB MECH
fop LICENSED CONTRACTOR'S DECLARATION IOb Description 1 hereby affirm that l am lum ued under Provisions of Chapter 9(commencing
with Suntan 7000)ofDivision 3 of me Business and Prafesaiom Code,and my license is INSTL NEW MNMNT SIGN, 2 NON-ELECTRICL
In fall fume mad effKL
jpi License Class Li:.Is
H Dam Contrecbr
ARCHITECTS DECLARA770N
ONO 6 1 understand my plans$hall be umd as public recent,
y0 Licensed Professional
OWNER-BUILDER DECLARATION
Q 9 1 hereby.(Rase that i 1. ,Bumps Imre the Canuacmfa License Law far tie
i p O following mason.Permit
t 703 L3,m afneu and w.deions CWC:My clay or county
$ which rtgoims issuance,permit to consuve aline,prow,d.moron,a lmash ed gamum
_Zy Prior70 is end alsoaauims the applies,for sohputmis70filea Law statement
FEC that(commencing
wit parw.m to don of Division
ofaha the
Limns lsw(C omCae9 Sq.Ft. FIOOLArea Valuation
Sat that he is exem with Sectionsto and of D alis f r of al aged&mod ProAny vi Cade)or $20000
That io h)temps memfmm and use buss for the CU the ewiCUL to Any viohdon of
Section than by Wary applicant for a Permit auhjeca the applicant so s civil penalty of 32607027 .�Number Occupancy Type
not mart than Ow 4undrtd dallan(f300).
❑I,as owner of the property,On my emPloyem with wagon u their win compensation,
will do the work,and de stwmum is not intended uraRered tarsale(See.7016,Business
and Pro(aw70ns Code:The Connector's License Law does amt apply to an own)r of Required Inspections
pmpeny who Wildaarimprow themon.and who doessuchworkMmselfor through his
awn employee,provided 021 such improwmenu are not intended arartercd formic.If,
howavee to Wilding or impmwmant Is sold within one You of comphtion,she owner
builder will haw the Wnten of proving dant he did set Wild or Improve for purpose of
al.j.
❑1,a owner of the PrapertY•am,Bclosively connecting with licensed antaamars m
constmm the projec,(See.7014,Business and Profusions Code:)The Convector's U.
come law does not apply 70 an owner of property who Wilds or improves maroon,and
who contacts;tar such pmjecu with a contactors)Ikensed pursuant to the Conuactor's
License Law.
❑I arta aempt under See ,B@PC for this mason
ser r�1'� Date 4f/fir/OQ
- WORKER'S COMPENSAtiON DECLARATION
I hereby of fou,under Penalty of perjury one of the follawins knewedom:
J ❑T haw and provided
far by Se CeN3ao of rho Labor
Code.
fur WurkeM1 ce of ft
work f u which this
(re mi Section o 7700 of tiCa Isher Code,far site arumaana of the
work for which osis permit is ivatl.
❑I haw and will red—Wm Workels ComPensstion Inwwace,as required by Section
3700 Office labor Code.for the PUO rmance of me weak(m Mlch this permit is iuuad.
My Wrolaces Compensation Inwnna amiss and Poll,number tie:
Cartier. Policy No.:
CERTIFIGTE OF EXEMPTION FROM WORKERS'
COMPENSATIONINSURANCE
ser law.)(ITh secllm need Out W compimed if the permit h for one hundred dollars($100)
I«asifY that In the performance of me work for which this permit is issued,1 shall not
employanyperaon in any memento o vase wbjrstao the Wmilmes'Compereadon --
LawsofCaliforcia.Dam
Applicant
NOnCE TO ABP AIqT.If,after making mh Geninete of Ewmpsion,you should
become to JAM the Worker's Compemation pmvisiwu of de labor Cock,you mug
rJ Q forthwith comply with such Pmvisiens or this Permit shall be domed mucked.
'z 0CONSTRUCTION LENDING AGENCY
(~ Thereby affrm Wee thew is a creass=tinn lending agency far de performance of
rl dm work fur which this permit is Wood(See.3097,Cl,
C.)
0.Q Lendm'a Name
z IsnAeta Add.
V Q 1 certify that I haw read this appllcadon and mum than me show information a
II,E correct.I agree m comply with all city and county oNlnanas and sum laws missing to
0 building construction,and hereby wthoew ustromnudes of this city to error upon me
LA ahow-ms,judg d pmpeny ford e puNan pugmwa V"'�!/VJN/
LL (We)agree to save,indemnify and keep harmhu the City of Cupertino against
any y ince liabilities, of the
expenses which may in any way acewe against said City
()7 A APPLICANT
of the granting S AND
(S7-// _
�7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON.POINT Issued by: Date
SOURCE REGU ATIONS.
's- 2LIi 5sli`n°4 Re-roofs
SISI of ApplsanmConmwmr Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum Wilding ocapantalon,rehandle husntou ro mrial
u dennen by the Cupertino Municipal Cod..Chapter 9.M and me Health and Safety
AN Nedc.S.xYen 25372($)7 All roofs shall be inspected prior to any roofing material being installed.
Yen
;K'Nu
Will the applicant or future Wilding occupied use equipment or devius which If a roof is installed without first obtaining an inspection,I agree to remove
emit hal-d-u all eonuminsnts an&Good by me Bay Amur Al,Quality Management all new materials for inspection.
Disrkt7
oYa
1 have mad the hmsntne materials requimmena underChaper6.95 office Califon
nia Health$Safety Cade,Scedoam 25505,25533 and 25534.l undersand that ifthe Wilding
does nos Currently haw s Cannot,met is h my mspamibiliay to notify de occupant of me
requirements which Wmet Pear to iwo...i s Conife.mofOccupancy, Signature of Applicant Date
Owner oe wmariwd gent Dau�f O All roof coverings to be Class'W'or better
a � '