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05040082CITY OF CUPERTINO BUILDING DIVISION PERMITcONTRACT,QR TN'0,12MA`C>€Q BUILDING ADDRESS: 230 STEVENS rRP.FP.K RT,Vn ARTS I GNS PERMIT 11% 5040082 ER'S NAME: PERMIT ISSUE DATE NETERION 165 SAN LAZARQ AVE 04/14/9.nos NE: - SANITARY NO. CONTROL NO. (408)245-7133 ARCHITECf7ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH l� l� CONTRACTOWS DECLARATION under of C 9 (rommense 1 Mmby affirm Net 1 am hose -. S I�Ot1� Bu Ptelona I, with Section 70lp)ofDivieion3oflM Business arw Profesaiona Code. And mylkcuc4 And ode. in full Toru and r e 51. 11SIGN--ILLUMIN.. LE Lkenxc , 4>c ik.t Dam Cutaneous ARS DEC us 1 end aruenJ my plana shall shall M used u public rteoras Q %G 2005 Licensed Professional OWNER-BUILDER DECLARATION OWNER-BUILDERDECLARATION _� 1 Mmhy alnt that 1 from the License Lew for the �'� BUIL following Dna Cade: Any city manly EO L0. Business and Pronwn, 'w`Ya■Y LANG requires • pctir re ennaWet, pMr, improv, or rtpair nuewm rens A MMIC 1 de s h punlfl, a ed Me the applicant for Con petit w tire. igned wmmcm prior w its ceased p also pursuant he ecmnwit pSTlenl lO Ne aINCCOnVYbr ad Sq. Ft. Floor Area Valuation (that Pnsclau(Chapwr9 commencingof Division 7 the Business and Code) Lir (commencing with Section7000)and basis f on. An vi Nu M ts aemDl tbert(rom and Ole buts for the alleged emsnption. Any violation of the the alleged 3 560QUirillie 0 Occupancy e P Y �'P Section 7071.5 by any applicant for a petit subjects to Applicml to a civil penalty of not mom than An hundred dollars (SSW), ❑ 1. a awsr of to pmpcny, or my wployen with wages As their sole compensation, Required InspecdonS will do to work,.nd Mannicture Is net Intended ora0emd Certain (Sec. 70th, Business W Pmfeweil Cade: The Contractor's License Law dace not apply w an owner of property who builds or Improves dime m, end who dao tush work himsal f or trough his own employcca, provided Nat such imp nvemenlssse nal inmwed offend forsale. If. hervever, Ne bulldingor Improvement is sold within ane year of rompleton, the smart, builder will have me burden of proving that M did not build or Improw for puryom of sak.L ❑ L as owner of Ne Property, am emlu,ively contracting with llcenaed sena ctort As cowmen the project (Sec. 7W, Business and Plefesswna Code:) The Contractor's LI- Cede law does not apply in an owner of property who Wilds or improves Neman, and who cents for such pmjecu with a contractor(s) licensed pursuant an Ne Conuantora Licets Law. ❑ 1 am uempt under Sec. . B d P C for this moon Dau WORKER'S COMPENSATION DECLARATION I hereby aRt under pemily of perjury one of the following declarations I have ow will maintain a Certificate of Consent to self-inure for Workers Camper. sown, As provided for by Section 3700 of the Labor Code, for the Performance of the work for which this petit is Issued. I have and will maintain Worker's Compensation Insurance, As required by Sects 3 of Ne Labor Code, for the performance oldie wndr for which this pormll is issued, My WorkLcta olmpemeton Inusse artier and Policy number=: Carder. /i . Policy No.. -03— w03" AV CERTIFIC OFEKEMPION FROM WORKERS' COMPENSATION INSURANCE (Thts codon need rot becompleted Ifthe petit Is i.e. hundred dellam(SI0B or test.) I Certify that in me perfom occ of the work for which Its petit is Issued, I shall not employ Any perann In my mmomran As w become subject in that Workem' Compensation Laws of cailf.mla. DAM Applicant NOTICE TO APPLICANT: If, afmr making this Cenincau of ExemNMr. you should become subject In Ne Worker's Compensation pmvWom of Ne Libor Coda, you must forthwith comply with such prrwumms or this petit Mail be doomed ranked. CONSTRUCTION LENDING AGENCY 1 hereby HE. that Vert Is a construction lending sgenry for the performanceof tan work for which this petit ts issued (See. 3077. Civ, C.) Lender, Name Lewers Add.... 1 certify that I haw mad Nis application And sells that Oc above informals is ' comm. 1 agree te comply with all city and county militiamen and sum laws relating w Wilding conservation, and hereby authorize mi msentstiws of Co. city to cnmr upon tic above-m IUmbCd property for inspects puryoses. (We) agree w save. Indemnify and keep hath, to City or Cupertino spinal liabilitin.judgments. costs and expenses which may in my way ccnm against mid City In consequence of the granting of this immil. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date SOURC• OULA ONS. Re-roofs Signemrt a ApplieanUConoaewr Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will one applicant or future Wilding occup ntstme aMndle huallous material u deOned by tan Cupenls Municipal Code, Chapter 9.12, and the Health and Safety ussz(a)7 Sectim,El you ❑res � All roofs shall be inspected nor to an roofing material being Installed. P prior Y g $ - If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future budding occupem are equipment or Junco which colt huartiaus air contaminants a defined by the Bay Ara Air Quality Management all new materials for inspection. Diui<n7 ❑Yo NO I have mW tan hoard... materials requirements underCMpmr 6.95 efts Caliror. ria Halt6Safcty Cade,S c6.25505,25f33md25534.lun&Tu Wihuifft Wilding Jots not cutnlly have a mnml, tut it is my responsibility w stify the occupant of the regmmr vwhiSbmust bemlpq to ummanCuufiamorOc�pycy��� Signature of Applicant Date All roof coverings to be Class "B" or better owner ar anmaducea em DDnm 2Y86 tJ n�F n Iggaa- 3y� FZ� 0C a`> air r7- Z UC 0� a �z CITY OFCUPERTINO� 3�'CiSNTRACTQR INFOl2MA BUILDING DIVISION PER BUILDING ADDRESS: ART S I G•N.S PERMIT N9b 5 0 4 0 0 8 2 V 2 NEWS NAME: PBRMF7ISSUE DATE NETERION 165 SAN LAZARO AVE n4/14/9,00c; PHONE: SANITARY NO. CONTROL NO. 408)245-7133 ARCHMECTIENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH LICENSED CONTRACTOR'S DECLARATION Job Description 1 hereby affirm that 1 am licensed under provisions or Chapter 9 (commencing with Section 700) of Division 3 of the Business and Professimn Code, and my licence is in full Tot¢ and ffe t jue,g 51. % SIGN--ILLUMIN. LETTERS Lmenmie t D }C Deb t Co.,. , ARCHITECTS DECLIMATIO14 1 understand my Ileo shall he used as puM1lic records Licensed Prnfeasionel OWNER -BUILDER DECLARATION I hereby affirm Nat 1 em exempt from the Comnaor's License Law for im following reason. (Section 703 1.5, Business and Profesaion Code: Any city cit county which requires a Ismailia coranract, alter, improve, demolish, or repair any structure 300 prior Io its issummo, ass roquitesthe applicanl far such permit m file a signed statement that he is licensed pursuant to Me provisions of the Contractors LIYnC Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7") of Division 3 of the Business and prepositions Code) or Mat he is exempt therefrom and the basis for Ne alleged exemption. My violation of e10 0 Occupancy Type Section 7031.5 by Any applicant for a permit subjects Ne Applicant I .. lint penalty of =I more than five hundred dollars (SSW). ❑ 1, As owner of the property, or my employees with wages as their mile compensation, - Required Inspections nsuous will do the work and the suuaure o not outdid or offered for mile(Sao. 7044. Business And Professions Cade: The Continuous License Law does not apply to an owner of q P prop -sty, who builds or improve thereon, and who does such work him¢elfor through his cash improvements tienear ded for saw. owntier, eWiProvided neIf, . thepr of the owner builder, , Ne building or Improvementisveld within one you of mprove for builder will have the burden of proving Net he did not Wild or Improve for pugwae of ssls.1. , u owner of the property, exclusively conuaning with licensedCconmcbn i. Cj p consumer the protean (Sec. a4, Business am Code:) The Camnemr's . B as ray who Wilds cid who Law tiara not apply ja m owner of property who Wilds or improves thebon, and for each projects with a contractor(l) licensed pursuant b the Conbutor'A whonse 0 Law. License Law. 1 em exempt under Sec. . B & P C for this resaan �O wool Dab WORKER'S COMPENSATION DECLARATION I hereby affirm under penally of perjury oro of the following declaradmm ❑ I him and will maintain a Certificate or Conant to self -Insure for Worker'sComport. saMlon, As provided for by Section 37M of the labor Code, for the performance of the work for which this permit is issued. I ban and will mairWn Work's Comperuedon Inanrance, As required by Schon 3 of the Labor Code. for Ne performance of the work for which this permit is Issued. My Worker's Compensation Insurance carrier and Policy number am: — -Carrier.l No.7T-O E%EMPolicy CERTIFIC FROM WORKERS' MON COMPENSATION INSURANCE (Tho section need not he completed lithe Permit Is nature hundred dollars (SIM) or legal 1 comfy Not in to performance of the work for which this permit is Issued, I shall not employ mypcnon in any manner¢ As to become subject in the Workn'Compcnsadon Laws of California. Dote Applicant Nonce TO APPLICANT: IL after making this Certificate of Exemption, you should become subject to Ne Worker's Compensation provision elite Labor Code, you mum forthwith comply wit such provisions or this permit shall be deemed remind. I CONSTRUCTION LENDING AGENCY 1 hereby aline that then is a conuuctinn lending agency for the performance or the work fm which MiA permit is issued (Sm. 3097. Civ. C.) Lender's Namc Iandeh Address j 1 cenify that I hats read this application and sum Net the above infmma0un 11 co..1 agree le comply with all city and county ordinances and gob I. mlaing to Wilding convection, and hereby authodm represemaims of this city to enter upon the above-mentiunud property for inspection purposes. (We) agora m save, indemnify and keep harmlras the City of Cupertino against j 1obilitleajudgratma msmil a.,.., which may In my way accruce gamusaid City in consequence of the granting of this Permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURC}' :GULA ONS. Re -roofs Signature o APIIm imCcoursc Date HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will tW applicant or future building Occupant nom or handle ha]ardaaS material As donned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety, codes Section zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed. D Yes No ❑ If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding occupant use equipment or devices which emit hazardous air contaminants As donned by the Bay Area Air Quality Management all new materials for inspection. District? 0 Yes Nu I have mW the hanedous materials requirements underChepter 6.95 of the Califon no Health& SaletyCoo, Section 235115,25533 and 23534.1 unhnsmnd daifdm Wilding does not currently haw Atenant, Net it is my responahility, w notify the Occupant of the inquire nmaaine II Pjar miavana argcamncam aromepytY.. Signature of Applicant Date ^wM �i1C�/� All roof coverings to be Class "B" or better owner ser authorivsd agate Dab • • a ft CITY OF CUPERTINO SIGN PERI MIT APP.T.Tr'ATION FORM b po y v G (�Z APN # �J d Z 3 / Date: Building Address: z2D.Z�A,o _6eye Crc'C<i� Owner's Name:�d/ r r l Phone #: Contractor: 5�� License #: Contact: ��I j I A I�viS Phone #: Applicant/Contractor: Seismic Commercial Building Permit Info: Bldg Elect Plumb Mech Job Description: �m/%xsGiil/>/9ei/ �Bt� Residential: Commercial: Sq.Ft. Floor Area: $/Sq.Ft.: Architect/Engineer: V aluation:4�3OU. U� Type of Construction: Occupancy Group: Qty. if ADDlicable Fee ID Fee De.ccrintion Fee Groun BENERGY Energy BUTLIDNG BPERMFEE Bldg Permit Fees BUILIDNG BPLANCHK Plan Check Fee BUILIDNG BSEISMICOM Seismic Commercial BUILIDNG EPERMITFEE Etect Permit Issuance ELECTRICAL BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL BREMSIGNS Rmdl Sings, Marquee ELECTRICAL BUSLIC Business License BUILIDNG Q- UJ6-�� 0 4((7. ?� 7m f, C I V) N F • eA T -fl' .vmhnl QO 5 h 5 MI O • 9 N g m z E O _D is 4 T <Cn UVJ64 f -sr 921V g O NN—r M mfmC 04iO GnC n g a GS Z-• n) A Z u� 0 1/2' 6' N v �co _ Z m� .9 2 G N CD IQb W • -n <[n==M _. -� fn 4 ,O ZZ �p A A d Zcn cn C7y � rnmca�De.�i Er N m r D O Z c w == p N C IZV Aco �z m CO N CII C/) T =' C4 CD y a cc' C o)