03110124TY OF CUPER'1'INO
CONTRACTOR INFORMATION, $�
BUILDING DIVISION- PERMIT
F.�C"
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DING ADDRESS:
MID WAY SIGNS
PERMIT Nt03110124
875 STEVENS CREEK PLVD
.R'S NAME:
PERMIT L55UE DATE
TURY FURNITURE
3290 BASSETT ST
11/20/2003
NE:
SANITARY NO. CONTROL NO.
(408)982-9696
ARCHITECrIENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMO MECH
t� t� 0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm Nat 1 em licensed under provisions or Chapter 9 (commencing'
with Sectiom mmy7)(Xpef Diviaion3ofNCBusncasandPchessions Coc.admyliccsia
dN
SIGN --ILLUMINATED CHANNEL LE
LiceseCI a Lie. X
��
Dam r
TS
�./ RCHITECTS DEC
r
1 unMnund my plans shall he used a public recounts
/I
APR O .y01
Licensed Prreuionsl
OWNER -BUILDER DECLARATION
U C U4
1 hereby .(firm I ore exempt from Ne Contractor's License Law for the
Comm:
following moon. (Section 703 1.5, Business and Professions oAny city or county
on
which mquires a permit to comm"t eller, improve, demolish, or repair any suucture
/ 0 0 0
prior to its iuu.nee; ala. requires the applicant for such permit In file a signed Ratement
the he is licensed pursuant mlhe Provisions of the Contractor's License Law (Chapter 9
Sq. Fl. Floor Area area
(commencing with Section 7fam of Division 3 or the Business and Profcscinm Code) ser
Nat he it; exempt Nererrm And the basis for the alleged exemption. Any vlolemn of
Section 7031.5 by arty applicant for a permit subjects Ne applicant to • civil penalty.(
e
Occupancy Type
...... Non five hundred dollars (SSOE.
❑ 1, as owner of the properly. Or my employees with wages as their sole compensation,
will do the work, and the swaum is not intended or offered for ele (Sec. 7044, Business
and Professions Code: The Cnmracmra Litems Law does not apply to an owner of
Required Inspections
propeny who builds or improves thereon, and whodocssuch work himself urthrough his
Avon cmployces, provided Nat such improvements ere not intended or offered forule. If,
however, the building or improvement is cold within one year of completion. the owner
builder will hes the burden of proving Nn he did not build or borrow for purpose of
se.j.
❑ 1, es Owner of the progeny, em exclusively contracting with licensed contractors to
construct the project (Sec. 7W, Business and Professions Code:) The Convactori Li.
cense raw docs not apply to an owner of propeny who builds or improves demon. and
who contracts for such projects with a conuen.gc) licensed purauam to On C.n"clor's
License Lew.
❑ 1 em exempt under Sec. . B & P C for this reason
r Date
'
WORKER'S COMPENSATIONDECLARATION
1 herby aBinn under Penalty of perjury ore of the following declarations:
1 haw and will maintain a CenConsent n
iocate of Conseno self-insum for Worker'sCompa -
ation, as provided for by Section 37M of the labor Code. for Ne performance of Ne
work for which this permit is issued.
1 has end will mein sin Workch COmperua Rm Insurance, as roquined by Section
3Tmof NC Labor Code, c he of Ne work rot whit Nis it is iauetl.
performance pe
or : 'a . { IB IMIYia i rad ni be
`
•1 7 fE ONFROM RKERs'
CO..hgg..�lE T/{OL1) INSURANQE//—
tNS
(Th I n c otNCOT ICICtl�Pllte permit is fnrenbTulftl�r£a .Iles Iq0
nr lux)
1 certify that in the performance Of the work for which this Permit is Wood, I shot l not
employ any penin in any mannerm as to become subject o the Worlsom' Compcosatlon
Uws of California, Due
-
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Crude, you most
forthwith comply with such prnvisinns or this permit shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm Nal there is construction lending agency tar the Performance of
Ne wash fur which this permit is iuued (Sec. 3097, Ci, C.)
Under's Name
Under's Addrou
1 Molly that I has read this application and sumo Net Ne,bow information is
Correct. 1 agree to comply with all city and county ordinances and sonic laws relating to
building construction. and hereby amhoris representatives of thiscity to enter upon the
ahovc-mentioned property for inspersion purpose&
(We) agree to now, indemnify And keep harmless, the Cil, of Cupertino egnme
liabilities,judgroons, casts and expenses which may in any way accrue against aid City
in cnnsquence of the goring Ibis Perm=.
APPLIC UNDERSTAN ND WILL COMPLY WITH ALL N P01
Issued by: Date
SOU A /f__^�__/
Re -roofs
sign rs p tnZARDOUS
MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building Occupant store or handle haaNuus material
az do food by the Cupertino Municipal Code, Chapter 9. 12, and the Health and Safety
s on zss3zta)? ......//////++••••
Y'sh
All roofs shall be inspected prior to any roofing material being installed.
Wm late applicant or future building
If a roof is installed without first obtaining an inspection, I agree to remove
occupant use equipment or devices which
II haoartlouc air c.ohmonants a defined by the Bay Amo Air Quality Management
all new materials for inspection.
....icR
❑ Yea
1 have read the haaNnusmaterols requirements under Chapter 6.95 of the Collor.
nii He.lO & Safciy Calc, SccomM2 515,25533 and 25x34.1 undo xam Not if Ih. muni,
d. no, a uIkLrm res ihilityto nodl'y NBC, tttf�
ata 01
re...mmC chmust Sq m' . ere/
Signature of Applicant Dale
All roof coverings to be Class "B" or better
Ownerratiltnn,,dd dkohl V Dam
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CITY OF CUPERTINO
BUILDING DIVISION
f"'C0NTRACT0 IN R Q
BUILDINGADDRESS:
MID WAY SIGNS
1ERhdITNc03110124
19875 STEVENS CREEK BLVD
OWNER'S NAME:
PERMIT ISSUE DATE
CENTURY FURNITURE
3290 BASSETT ST
11/20/2003
E:
SANITARY NO. CONTROL NO.
(4 08) 982 - 96 96
ARCHITECDBNGINEER:
BUILDING PERMIT INFO
MECH
BLDG ELECT PET
0 t 0
LICENSED CONTRACTOR'S DECLARATION
Description
I hereby eau. that I am licensed under provisions nl Chapter 9 (commencing
.lob
srndPoressiuns Cod.anemylcensei
wiDnilSl ercntrip70b0)of D.km3ofbe Buks.inN
e(
License
LCodr!a!
SIGN--ILLUMINATED CHANNEL LETTER
armhY
RCHITECTSDECAyd
TIW-
1 hmraml my plans 0,11 he used a+ public tommis
,
Licensed Poura,h n d
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from tlm Comrscmf+ License Law for the
following reason. (Section IID L5, Buima+and Prorexdom Cods: Any city or county
which mquimn A permit to enefeuct alma improve, demolish, or repair any structure
2 S O O 0
prior us its issuance. also ruinous the applicant for such pnmh to rile a signed statement
that he is iimased pursuant W the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
scommeneing with Section ?o W) of Division 3 of be Business and Profwinm Cook) or
Nn he Is eumpt tMmfram antl bac bun tar Ne alleged ezemptim. Any violation Of
Section 7031.5 by any applicant for A permit Aabjeeta the appIk4m 10 a civil penalty of
@
Occupancy Type
not more Nan five hundred d011an (5500).
❑ Lotowner pmpmy, ar myemployees WINwagsuheir hak compeuAon,
,the
will Pr a work, and lure: aWC on is lm intended , a w do for isle (Sec. 7044, an owner of
and Professions Cade: The c License law does not apply lm an owner
Required Inspections
whobu is
thereon. and doessAmmer chwoikhimselforNrough his
phurenOwn
orimpmvuch
/
mo
Own employttt provided is If,
pro imromme mo0ernd for
ver improvements art not lar
owk.wn
however, the building poo ofc N
improvement is hath within one year ofcompletion,
,!1/g{'//%_
for
Wilder will have dm burden or proving Nes he did not bulla or Improve for purpose or
a purpose of
44Z
311/1
❑ 1. as t the p of the Property, , B exclusively confessions with :licensed Cconlrhalrs U.
construct (See. 70x4, Business and Prolusions Code:) Contractors
e
*/IVY
it not
law dose not apply je an owns or property who rs improve Neuron• and .
pro and
Y
who
whocontractsLace for such pmjeeta with a conlracmrt+7licemed purwant W Ne ConuanoM1
sed p
License law.
❑ I em exempt antler Sec. , B & P C for this mason
'
Owner Data
WORKP.RSCOMPENSATIONDEC "TION _
hereby AM. under penalty, or perjury oro or Bre following declarnimo:
k1
e ve And will maintain • Cmdfinm ofConsem to selBinsum for WorkeYACompen-
u pmvided for by Section 37M of be fabm Code. for the pedomurice of the
work For which Nin permit is issued.
Wmker'+Compensation Wunnm, u myuimd by SceJon
At cpertormanccotcheworkforwhic Of pc it is issued.
n Inunn Ad nY be ase:
9NOin
A (Ek ON FROCO�h}yPlENwSA(T(ION)
INSURAN E/,N
Et61rIbN'di�m i BriCTuIMrCH t( of c permit le for Ilan/ IBri)
or los.).
I cenify Nat in the performance or the work for which his Permit is issmd, I about not
employ any person in any manner An U to become mbjec00 the Workeeri Compensation
Laws of Cath ornia. Dam
Applicant
NOTICE TO APPLICANT: If, after making hi. Cenifmam of Exca ptian, you should
become suhject to the Worker's Campcnsation provisions of the ISM, Code, you must
forthwith comply haw such prnvisinm or did. N mit shall be deemed invoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that Nem is a construction lending agency for the performance of
the work for which thin permit is issued (Sec. 3(197. Civ. C.)
(antler's Name
IsMer's Addmsn
I certify that] have read Nin application and tutu that the above infamutiun is
cmtaa I agree to comply with all city and county ordinances and auk laws minting to
Wilding construction, and hereby Authorim mpmsenmdma of this city to mor upon be
above-mendoMd property for Instruction pur rota
(We) agree W save, indemnify and keep humleas the City of Cupertino against
Ihbilitie.judgmems, costs and expenses which may in any way ammc against said City
in consmiunce or Ne grant of Nia Permit.
APPLICANTUNDERSTAN ' ND WILL COMPLY WITH ALL N P01f{f
Issued by: Date
SOU E A si /
Re-roofs
Type of Roof ,
�1 0'26f
fff/v
Sign to p GO Or Date
AZARDRD OUS MATERIALS DISCLOSURE
Will the a or future bullingentre or handle hazardous mammal
Cupem
As defined by the Cupertino Municiptl.Cotle. Chapter 9.13, and the Healb and Safety
k, Chapter
Catle Yu 25533(a)?
All roofs shall be inspected prior to any roofing material being installed.
/y.�(1�Na
If a roof is installed without first obtaining an inspection, I agree to remove
W, a aptrlicant or r" ulun building occupant un equipment or Jevice+whkh
W_ ac phous air mnumin� defined by the Bay Area Air Quality Management
all new materials for inspection.
Wr
Yc+
I have and Ne huadmamueriala,cquimmema i mkr Chap or 6.95 of the Celifop
ria He.]" SAfmy Cmd, Somom 505.35533 and ISS3d.l undon d,hal building
Jura not currently hit emit U Y rt"Amu '" W notify the upent re Ne
P-7u,
myuimm ch muse et ryG�n cu _
'�
Signature of Applicant Date
�h%G
`b �Da
All roof coverings to be Class "B" or better
.4
owner, .a r,v da m.
0
• CUPEk INO
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• CITY OF CUPERTINO
SIGN
PERMIT APPLICATION FORM
APN # N 2/
Date:
Building Address:
Owner's Name: C
1 1
#:
Contractor:
License #:
Contact: j
Phone #:
Applicant/Contractor:
f =( f)
Seismic Commercial
Building Permit Info:
Bldg Elect Plumb Mech
Job Description:
Residential: �171 /-�—Cohunercial:
Sq.Ft. Floor Area:
$/Sq.Ft.:
Architect/Engineer:
Valuation:
�eol
Occupancy Group:
Qty. i
Anuli blel
Fee TD
FrP T�rcrrintinn
Fru (:rnnn
BENERGY
Energy
BUILIDNG
BPERMFEE
Bldg Permit Fees
BUILIDNG
BPLANCHK
Plan Check Fee
BUILIDNG
BSEISMICOM
Seismic Commercial
BUILIDNG
EPERMrrFEE
Elect Permit Issuance
ELECTRICAL
BREMSIGNAD
Rmdl Signs Add Branch
ELECTRICAL
BREMSIGNS
Rmdl Si ns, Maz uee
ELECTRICAL
BUSLIC
Business License
BUILIDNG
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JOBNAME MMIKYRIMMME DATE:
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