05080251CITY OF CUPERTINO
INFORM OOH,
BUILDING DIVISION PER
,C�NTRACIOR
BUILDING ADDRESS:
ALLEN SIGNS INC
PER MIT NO.05080251
19028
NE R'S NAME:
PERMIT ISSUE DATE
CUPERTINO WELLNESS CHIROPRACTI1982
STONE
2005
E
SANITARY NO. CONTROL NO.
(408)280 -6500
ARCHITECIENGINEM:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECN
I� 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I harehy affirm Nat 1 am licensed under pmvisions of Chapter 9 (commencing
With Section 700B of Division 3 of the Business and Professions Coda, end my license is
incfe^I�me and effepg. x, (>`
SIGN - -1 ILLUMI. CHANNEL LETTER
Lk M'
Data Contractor
ARCHITECTS DECLAR TION
I understand my plans shall he used as public men
Licensed Prefcasio ul
OWNER-BUILDER DECLARATION
1 hereby affirm out 1 am exempt Crum the Contractor's License Law for the
following mason. (Section 7031.5, Business and Pm2ssions Code: Any city or county
$2000
which mNiru a Permit in Consumer, alter, improve, demolish. nr repair any structure
! pd.,. its issuarce. also.,. I. the applicantI .... Ch Permit ofile signed statement
y
Sq. Ft. Floor Area
Valuation
that he is licensed pumuanuo the provisions of the Contractor's Liccnu Law (Chapter
(commencing with Section 7000) of Division3 of the BUainemand Proutdons Code) or
: that he b exempt themfmm and die basis for the alleged exemption. Any violation of
Slctlon 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
Occupancy Type
not mom than five hundred dollars ($500).
the pmpeny, aemyemntended- INwred(-'-to (Se. co
Lo
Required n$ ections
9 P
the work, and ,Business
will do the Care: h. C.reisrm.License Law net pply 7044, owes, of
ou Cade: The Contours Law does net apply lf router or
ma property wh nd who rt
eny who buildsorimpmws Hereon, end who des ouchended ourself or dtmugh his
own foe
.,ping
or i promhimpmwmenuartnetiorr ofcmoQemd
own,.
however, the building or improvement Ia sold within one year of completion, Nc owe, -
however. he
builder will have the burden of proving that he did not build or Improve for purpose of
We.).
❑ h as owe, the property, em exclusively contracting with licensed comae t-
consumer aj and fousi es
La due project (Sec. 7044, Bnet of and Professions Code:) The Committees Lid
law does not apply . net of property who builds or improves thereon, and
(/
mme
reuse
who conuacu for each pmjecu with s c&ntnclor(s) licensed pursuant. the Convanar's
,
License law.
1 am exempt under Sec. . B A P C for this reason
wm Date
WORKER'S COMPENSATION DECLARATON
1 hereby affirm under penalty of perjury arse of the following decluations:
❑ 1 haw and will maintain a Cenifiente of Consent 10 ulHnsuu for WorkersCampen-
.it.., u provided for by Section 31W of the labor Code, (or the pefemanm of the
work for which this permit is issued.
,
I have and will maintain Worker's Compensation Insurance, as required by Section
of the labor Code, for the performance of the work for which this permit is issued.
My w.de�'lle: *�C..Petul!a)d)on morn. under and Polity n an,txar �Inat
"'1r1f.�m!'�5 Policy No.: A14/ IA
Cartier. .�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he Completed Kthe permit Is for one hundred dollar (glop)
wo.)
1 certify that In the performuncc of the work for which this permit is issued, l shall out
employ any person in any manner so as to became subject to the Workers Compensation
Laws of California. Dam
Awlmmil
ND NCE TO APPLICANT. If, after making this Certificate of Exemption, you should
become subject to the Workers Con, ceatlon provisions of the labor Code, you must
this shall he deemed mmlod.
? forthwith comply with such provisions or permit
CONSTRUCTION LENDING AGENCY
1 hcmby &from Nat there is a construction lending agency for the perrormanct, or
.
> the work for which this pmmit is issued (Sec. 3097, Civ, C.)
Lenders Name
'
Lenders Address
I certify that 1 have read this application and state that the &hove information is
coneca 1 agree to comply with all city and county ordinances and sou laws relating to
building COnswclion, and hereby euthorix mprrxnutivcs of this city m anon
abovomentianed pmpeny for inspeCLian purposes.
ag. mt
3. (We) agree to save, indemnify end keep harmless the City of Cola n r against
A liabilities. judgments, costs and C.Cammu which may in any way accom again, said City
Zin consequence of the granting of this perm it.
APPLICA UM ERS'TA DS AND WILL COMPLY WITH ALL ON INT
i'�,.ya�r
Issued by: Date S F�
SOUR A 1
K� Z-
Re -roofs f :2ir
1 J pe of Roof
Sign4t rebfApplica VC none., at`
AZARDOUS MATERIALS DISCLOSURE
Will the, cam orfu.m building occupant store or handle halme us material
as defined by the upenino Municipal Code, Chapter 9.12. and the Health and Safety
Code, Setlon25532(a)l
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ®Nu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fu.te building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
C] Yes Nu
'
(hove re the hvaNnus ma.rials rcyvircmcnts under Chapter 6.95 of the Cali for
4 Jf
nix Health & SdoyCWe, Sections 25505, 25533 and 25534.1 understand the if the building
VVV
Jose notcup ntly wait. t, do, ltumy mspouihility .nmiry theatupent of NC
ragaire me us, hP wrier. issuance ore Ccnifieau or a,ne.
Signet iC Of,Apph ant Date
All roof coverings to be Class "B" or better
Owner m, amng drea gat Dak
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FEE ID
BPERMFEE
BENERGY
BPLANCHK
EPERMITFEE
BREMSIGNS
SITE ADDRESS .....: 19028 STEVENS CRK BLVD # D
SUBDIVISION .......
CITY .............:
IMPACT AREA .......
OWNER ............: CUPERTINO WELLNESS CHIROPRACTI
ADDRESS 19028 STEVENS CRK BLVD # D
CITY /STATE /ZIP ...: ,
RECEIVED FROM
CONTRACTOR ...
COMPANY ......
ADDRESS ......
CITY /STATE /ZIP
TELEPHONE ....
WNWIN
VALUATION
PERMIT FEE
PERMIT FEE
FLAT RATE
NO SIGNS /MARQ
VALUATION
TOTAL PERMIT :
KIMBERLY LIN
ALLEN LIN LIC # 22174
ALLEN SIGNS INC
1982 STONE AVE
SAN JOSE, CA 95129
(408)280 -6500
QUANTITY
2,000.00
1.00
1.00
1.00
1.00
2,000.00
83.16
34.86
83.16
38.37
23.98
0.63
MEtHOD OF PAYMENT AMOUNT NUMBER
PD -TO -DT
0.00
0.00
0.00
0.00
0.00
0.00
0.00
THIS REC
83.16
34.86
83.16
38.37
23.98
0.63
264.16
kfaftm =)eff
0.00
0.00
0.00
0.00
0.00
0.00
0.00
OTHER, 264.16 VISA
TOTAL RECEIPT 264.16
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
•
CITY
OF CUPERTINO
1 of 1
PERMIT RECEIPT•
OPERATOR: conniew
COPY # 3
Sec: Twp: Rng:
Sub:
Blk: Lot:
APN ........:
37511071.00
DATE ISSUED.......:
08/29/2005
RECEIPT #.........:
30969
REFERENCE ID #
...:
05080251
FEE ID
BPERMFEE
BENERGY
BPLANCHK
EPERMITFEE
BREMSIGNS
SITE ADDRESS .....: 19028 STEVENS CRK BLVD # D
SUBDIVISION .......
CITY .............:
IMPACT AREA .......
OWNER ............: CUPERTINO WELLNESS CHIROPRACTI
ADDRESS 19028 STEVENS CRK BLVD # D
CITY /STATE /ZIP ...: ,
RECEIVED FROM
CONTRACTOR ...
COMPANY ......
ADDRESS ......
CITY /STATE /ZIP
TELEPHONE ....
WNWIN
VALUATION
PERMIT FEE
PERMIT FEE
FLAT RATE
NO SIGNS /MARQ
VALUATION
TOTAL PERMIT :
KIMBERLY LIN
ALLEN LIN LIC # 22174
ALLEN SIGNS INC
1982 STONE AVE
SAN JOSE, CA 95129
(408)280 -6500
QUANTITY
2,000.00
1.00
1.00
1.00
1.00
2,000.00
83.16
34.86
83.16
38.37
23.98
0.63
MEtHOD OF PAYMENT AMOUNT NUMBER
PD -TO -DT
0.00
0.00
0.00
0.00
0.00
0.00
0.00
THIS REC
83.16
34.86
83.16
38.37
23.98
0.63
264.16
kfaftm =)eff
0.00
0.00
0.00
0.00
0.00
0.00
0.00
OTHER, 264.16 VISA
TOTAL RECEIPT 264.16
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
•
Ee - CITY OF CUPERTINO �3 Z, � Z S -/
SIGN
SCUPEkTiNO PERMIT APPLICATION FORM
I
r�
APN #
S
BENERGY
Energy.
Date:
Bui ding Address:
o s4ejms
Cr
Bldg Permit Fees
BUILIDNG
v #.D
Owner's Nam :
BUILIDNG
Phone #:
Seismic Commercial
E/
e C'�tir a
Contractor:
S,
Inc.
License #:
83s8o
EPERMITFEE
Contact: U
ELECTRICAL
Phone #:
Rmdl Signs Add Branch
ELECTRICAL
BREMSIGNS
Applicant/Contract :
ll
ELECTRICAL
(-.
Building Permit Inf .
Bldg
Elect
Plumb Mech
Job Description: r
n n
cha n n S�
Residential: Zy1S'I
t E
<ommercial:
Sq.Ft. Floor Area:
$ q. t.:
Architect/Engineer:
Cost o/f� Project:
Type of Construction:
Occupancy Group:
Qty. if
Aoolicable
Fee 117
Fee Dew.rintinn
FPe (.ruin
if
BENERGY
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
�3�7v
CITY OF CUPERTINO
'
BUILDING DIVISION PERMIT
X ONTRACTOWINFORMATION -
BUILDING ADDRESS:
ALLEN SIGNS INC
PERMIT N005080251
19028 STEVENS CRK RIND it D
OWNER'S NAME:
MMUTSSUEDATE
a CUPERTINO WELLNESS CHIROPRACT11982
STONE AVE
_____03j23_L2005
I E:
SANITARY NO. CONTROL NO.
(408)280-6500
ARCHITECT /ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I beaby affirm that I are licaussad under provisions of Chapter 9 (commencing
with Section 7M) of Division 3 ofiloc Business and Professions Code. and my license Is
un Fail to
L 8��W_
4ia��
SIGN--1 ILLUMI. CHANNEL
FINN ED
Con
PT"
. mar
I ARCHITECT!. DTLR I N
S'
I unclasuand my Plans hall he used as public a
OCT 1% 2005
Licensed professional
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from ft Conernam's License Law for the
following moves. seciian 703 1.5, Business and Professions Code: Any city of county
which requires a Permit to construct. sluo, Impound, demolish, at repair any sanctum
pdorwiuinuance,slmmquim0loapplimiforswhpcmitto0ie,sigmdsmmment
thiet W is licensed pursuant to that powishous of the Contractor's Licamen Law (chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business had Profession, Gain) or
,
Nat he is combat thienfrourne and ft basis far the alleged assumption. My viDiall on of
-3 APPRRIFaM
Occupancy Type
Section 7031.5 by a" applicant for a permit objects the applicant M a civil penalty Of
am mom than five hundred dollars (5500).
❑ 1,Uo offtpmpmy.wmy=ploymwiowrAuftirwle=pcnudan.
Required Inspections
.ill do thawarkindthaimanclure limthmanddrooffered forsatc(Sec.7044.Business
and Propessions Code: The Comacures Liccourn Law does, me, apply an an ow er of
property who tattildsorimparmum thereat, andwho Owes suchwerrichimselfor through his
Own employces, provided that such improvements are not intended wafferad forsake. It.
however. the touldhot, or improvement is sold within own year or completion, line maraca,
builder will have the human of proving that M did not Wild or loapr0w far purpose Of
"]a.).
❑ I. as owner or the property, am exclusively contracting with ]!caused conetwelors to
construct line project (Sec. 7044, Business and Professions Code:) The, Cominacter's U-
cash, Law does not apply un an owner of property who wilds or impearms disencer. and,
who commuch; for ameh projects wish a contriciourfs) licensed pursuant in the Contractor's
License Law.
❑ 1 ma troops under Sec. . 8 & P C (a this mason
Owner - Data -
WORKER'S COMPENSATION DECLARATION
I herby affirm under penalty of perjury am of the following declaration
I haw ant will maintain a Centificade.1' Consent th self -inure for Woftes Cbrrpm-
sation, a provided four by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
I ban had will maintain Worker's Compensation Insurance, as required by Section
of the Labor Conn. far the racufarmance of dha wealle for which thin Permit is issued.
.
or so acynoth ram,
My Workie�. be
�cd Pander 7
Carrier: Policy No.: 11(
OF EXEMFIION FROM W(�RKIERS'
COMPENSATION INSURANCE
(-rithacendon road wt completed tifthe permit 6 farm hundred dollars (SIM)
or I...)
I certify that in the psoficarnmeac, of the work for which this permit is issued, I SWI not
employ anypersan in my member so as at hmome subjwt to Na WorlacreCompenstation
Law, of California. Dale
Applicant
NOTICE TO APPLICANT. If, after making the, Certificate of Exemption. you should
become subject W the Warlact's Compensation provisions of she Labor Code, you raw,
rundrovidt comply with such powid. or thi. Permit "I be decreed revoked,
CONSTRUCTION LENDING AGENCY
I barely am. shot ftn isa comessurecam. keding agenry for the pcf....(
the wok for which this permit Is issued (Sm. 3097. Civ. C.)
I..dcrs Name
Landeur's Address
I cemity that I haw read this application and show that the &Ww information 4
cornment. I &goes as comply with all city and county ordinances and town 14" relating to
Wilding construction. and thereby authadm representatives, of this city to color upon the
above- mentioned property for inspection purposes.
(We) Ilpres: to an, indemnity and keep hormleass Los, City of Cupertino against
liabilities, judgments, canal, and axperma, which may in my way .rue against said City
in consequence of the granting Of this permit.
APPLICA U ERST*VDS AND WILL COMPLY WITH ALL)tON,915INT
Issued by: Date
SOUR MA'qw I
_
elwol
Re-roofs
Type of Roof
Signal re 4Apfic VaRIONCLOu Ilan,
'C
AZARMUS MATERIALS DISCLOSURE
I it canto (at. Wilding occurentstam Or had]. harstabous, material
t 0
as by ft .1senfirm Municipal Codc. Chapter 9.12, and the Health and Safety
Code. Section M532(a)7 I
All roofs shall be inspected prior to any roofing material being installed,
,
th❑Y. No
If a roof is installed without first obtaining an inspection, I agree to remove
Will lAe, applicant or Tutu building Occupant use equipment ot devices which
hazardous air carturnimmut u conned by the Bay Area Air Quality Management
all new materials for inspection.
District?
Oyer
16N.
Ih w mad theloachdousauserials requirements underChopherii.95 offtCAlifor.
ni.H.INm;Szfc,yCam,Swd=255M,25533and2SS34.lun&�undftifftWilding
due, not '. tly w
itto my mesponsibifil,ran unity thpoocepart, or the
ft;. ZLht
require hk I ifteninuxxxta'a no CA
a "War
gignatbre li ant' Date
TJ All roof coverings to be Class "B" or better'
'raw
ar'or ant jS4