05030194CITY OF CUPERTINO
'CtQN
BUILDING DIVISION PERMIT.CCSNTRACCOItINFU!<cM
BuILDINGADDRESS:
ALLEN SIGNS INC
PERMIT NO 05030194
R'S NAME:
PERMIT ISSUE DATE
E:
SANITARY OL NO.
ARCHITECTIENGINEER:
BUILDING PERMTf INTO
BLDGBLEU PLUMB MECH
r__1m! l�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby .M. that 1 am Iiceund under proviam s of Chapter 9 (Commencing
with Section 7ag0 afDiviaion 3 ofthe Business aha Profossiana Code, and my llceme la
I. mu forte andefresit. r uc ;a .3(y
Licensr�'Ipa
SIGN--INDIVIDUAL CHANNEL LETTER
_
., eonuact.
ARCHITECTS DECLAR ON
1 undernd my plans doll W used u public rtc.Ni
understand
Licemed Protestant
OWNER-BUILDER DECLARATION
I hereby affirm that I sen exctop, from the Contractor's License Law for the
fallowing reason. (Section 703 1.5, Business and Profeaduns Cade: Any city or county
which requires a $coni' M comms', Nen Improve, demolish. or repair any structure
(�
prior m its issuance. also requires the applicant (mach permit W file a signed statement
Nat he is licensed pursuant to the provisions of the Conuacur's License Law (Chapter 9
Sermon7000) of Division 3 of the Businev and Pror.m. Code)or
S(I.,Fiv064 Area' _L- on
(commming with
Any
^Valuat
v -
that he is aemp, m refrom and the basis for the alleged contortion. viohdon of
-
Secdon 7031.5 by any applicant for a Permit subjects the applicant m a civil penally of
3 6P1 't @t0 0 Oceu'pancy Type
not mato man five hundred delWs (5500).
\ ` 1
❑ 1, u owner of the property, or my employees with wages u their ate compenudon,
will dothe work. Codec sh oraffered 7044. Business
Reuired� ection
9 p
cuYa License Law dos ne, apply lf rt weer of
and Code; The Coomures ices wdenset apply
his
.
zt
en(esobu Improves m wohhimd(otmromh
propertywho builds m ed Chau therew,and whodunit annot or oroBend totals. if,
wnemployees, provided mprath Mprovemenu nest t.
s.
in
me building orimprovementhaid within one year of wmplefor me owner.
yeah o
'
builds will have W burden of proving that ha did not build or improve for purpose of
build=
ule.l.
❑ 1, as caner of the property, am uclusively contracting with licensed Conuaun to
Construct the projem (Sec. 7644, Baines and Professions Cade:) The Contractor's U-
arta Law does not apply m an owner of property who builds or imprew thunon. and
who contracts for such projects with a conhac7pr(s) licensed punan, to the Cornerstones
Limme Law.
❑l amuemptunder See ,Bd PCforthlsrttson
rDam
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury orc of the following Outlanders;
❑ I have and will maintain a Certificate of Cement an self-Insuefor WeambesCompen-
mun, u provided for by Sutton 5700 of the Labor Code, for the performance of me
work for which this Permit is issued.
❑ 1 have and will maintain WmkCe. Compemadan Insurance, as required by Section
3700 of the Labor Code, for the performance of the work forwhich this permit is Issued.
My'crimesC nsunna mins and Policy number an:
OdS—a00
Carrier. �p,�,� PolicyNa.: /p'LyS
CE911MAfE UFM PITON MOM WORKERS'
'
COMPENSATION INSURANCE
(This auction need notbecomplered if the Intent, is farone hundred dollar (SIM)
or tea)
1 anify that in to perfurmamm of the work for which this permit is Issued. I Nall net
employ any Noun in my manor an u or beamerobject so the Workers' eompcnYdon
Laws of C1111M la Dam
Applicant
NOTICE TO APPLICANT: IL afar making this Octdfam of Exemption, you should
become subject m the Workees Compensation provisions of the Labor Cade, you muss
foMwith Comply with such provisiau or this permit Nail be ducmed meted.
CONSTRUCTION LENDING AGENCY
I hereby alfrto that then is a construction lending agency for the perfurmemn of
!
the work for which m4 permit 6 Issued (Su. 3097, CN. C.)
Lender's Name
Landed Address
1 Certify mat 1 have mad this application and sum that me above Infowdun Is
cosec,. I agree to comply with all city and county ordinances and sure laws mlaling to
building construction, and hereby athorin ropresnsliw of this city to true upon me
above-mcmitua d properly far Inspection P OPOSCL
(We) agree 10 ave, indemnify and knep humus me City o(Cupertino against
j liabilities, judgments, casts and expenses which may in any way same against said City
I. I of the jolurniof this rmit.
APPLICCRND
ANTUNDESTADS ANWILL COMPLY WITH ALL NON-POINT
Issued by: Date
SOULA NS.
Re-roofs
Type of Roof
MLA
-.t 271Ot
Si{natuno Ap iearhUmussa e, die
HAZARDOUS MATERIALS DISCLOSURE
Will the applian, or future building occupant wort or Monte buallou material
as defend by the Cupertino Municipal Code. Chapter 9.12. and me Halm and Safety
, Section 25532(&)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
emit haurdnua air conumlmns u dcfmd by the Bay Area Air Quality Mutagcomm
all new materials for inspection.
District?❑ Ya 0.
1 have mad the hsardousmem ials requirements under Chapur6.95 of me Califor-
nia Hmith& Safcty Cedc, Swdons25505,25533 atu12553a, i undcuund muifec building
at it s my resmibili,y, u nd1'y me occupant of the
does not currently have a unanL mpe
nqun It Itch n be met pdonulesunceoh Ccurs!a of cuputry.
7
Signature of Applicant Date
All roof coverings to be Class "B" or better
O.vilir
tar shifficlind agent Date
a