02070015 OF
CITY
I nun DING DIVISION CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
20269 STEVENS CREEK BLVD SIGN A RAMA 02070015
a'9f fE'JENAB 1179 E HOMESTEAD RD APPLICAT61176T12002
'-s,_� PHONE: 4082437388 SANITARY NO CONTROL NO.
„G,o za ARCHITECTIENGINEER. BUILDING PERMIT INFO
w- BLDG ELECT PLUMB MECH
a z
izy i LICENSED CONTRACTOR'S DECLARATIONhh p �g p1t��❑ n
eo ne yarrnn diatlam Eam.ed ander pm ir,a.+ �renamervt<mmut<rdng SIGN (CHANNEL LETT��r�T/t'iI O VHALIE®
vs xt c ,7003 `Division J of the Business an roleaions Code.andmYlimme,
II cff•t.
u Limn.m f Lic,a
SIMCL /- SEP 0 5 2002
ARCIIITIiCT,edi m, l ed
c u 1 understand m planuhall he used ra p rc rtcnN. BUILDING p
W
ix0C7 Licensed frnfe+sinnal DICtl
OWNER BUILDER DECLARATION IS7UIL
vat m I hacby ollimt that I tun exempt farm the Cammctor's Lacune Lw for the
i-Z�' folhwing reams ISeaion 703 L5.Busimss end Professions Code:Any city or musty $3000
adF which requires a permii m comweL alter,improve,demolish,or mpair any structure
a.3,� pia t l c,
hmn he is licensed pursu aq the provisions
r inions of fNoer Consumable,
epenmfu3 License I I -drg eJ(Cmoaampmaer m9tee '< g 'ns«r arae} rn,isamJo0nnButne,
-- --
and Pr_ ',ii+eoae) I t<,, Valuation
or that he a exempt mcrefrdm and the basis for the alleged excinthon.Any violation
of Section 7031.5 byany applicant fora permit suhjeas the applicant to a civil penalty
of not tnnrethan five bandied dollar,(%5007, 107AP-NIIl1GDILINDATION Occupancy Type
❑L.,own<rmdoulole<mu,r,adun, 103 — UFER
will do the work.and do,structureis not intended or offered for sale(sec.7034, 10 4 — REBAR
Business and Professions Code.The Contractor's License Law does not apply to an Required Inspections
arse,of properly Who Wild—,improves thereon,and who due,such work himself 105 — ANCHOR BOLTS
or th
rough his own employee,.provided tom such improvements art out intended or
offered for sale.R,however,the building or improvement is vold within one year or 304 — ROUGH ELECTRICAL--
<candet ftnr the u.nen,buildcr will have me wmen nfpr°v�ing that heard not Wild or
im505 — FINAL ELECTRICAL
prove purpsaerye
". ol.dso nnfiheynpny, m xw.ieyeonimtingranEanuJ<ammaaom 514 — FINAL PUBLIC WORKS —
construct the project(Sec.7041,Business and Professions Cude:)The Contractor's
Lice i,law doe.+out apply to an owner of progeny who builds or improves thereon,
and who contract.for such Projects with a mntmaods).licemvad potatoes to the
Camra<mh License Law. _
❑1 am exempt under Sec. ,B&P C tonnis maven i
Own Data
f WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following dedamtions:
E
1 have and will maintain a Certificate of Consent to self-insum for worker's
-� Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this Permit is issued.
❑1 have and will mai main Worker's Compensation Insurance,as required by Section
37W of the Laoor Code,fur the performance of the work for which this permit is
i tuaL My Wmker's Compenudon Insurace ncanferand Policy number arc:
a - ..
� ',(. J'. Policy Na.: _..� . . •. .. ..
CERTIFICATI OFEXEMPTI fsWORKERS'
C MPEN SATION INSURANCE ' , ' .. - _.......". ..._... " ..... ...._._..._..
I"(This section need nut be<nmplemd if the Peolut is far one hundred dollars
S100)in less.)
' I eenifY that in the performance of the work for which this permit is issued,1 t t %I
shall not m employ any Perto any manner m as to become object m the Workers'
Comp<namion I.aw.or California.Dam'
.APPlicam
NOTICE TO APPLICANT.If,after making this Cenificme of Eumption,you should
Q Obeac schjarini the Worker's Cumpeasation Pit,i....r oftin Labor Code,you must
Bmhomwith comply with such provisions or this Permit shall ba deemed revoked.
^� .yam+ I CONSTRUCTION LENDING AGENCY
I hereby wins that them is a oinstmction lending agency fop the perfomtattce
br me work for'whi,h this Permit is issued(Sec.3097,Civ.C. -
d.Q Lender's Name
Q Z Lcndcr's Address
I certify that I have read this application and state that the above information is
kT+ [r correct.1 agree to comply with all city and county,oNinuntts and state laws relating
Q V to Wilding com uction,and hereby authorize representatives ofthis city to enter upon
� the above-mentioned property for inspection purposes _'. y (We)agree i,save,indemnify and keep harmless the City of Cuperiitio againn
-h liabilities,judgments,costs end expenses which may in any way acerae against said
�.) z City in .am,an of toe gm ming of this Knob.SOpp1�C T us ! S S(U/DL$��/! WILL COM-PLY WITH ALL N'ON-POINT Issued by: r Date
( r
mureof AppfieaMcontricun' 0" .' - �`XDate Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
f Willthe applicantor future Wilding oivpa
ant store or handle hazardous manal Type Of Roof
as defined - -- :- - -
ed hy.0.Cupertino Municipal Cole Chapter 9.12.and the Health and Safety
C.dc.Siadsia 25512( 7
0yesx ' ' ' - All roofs shall be Inspected.prior to any roofing material being installed.
Will the pplit rI reildiall account use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
cost hazardous it contaminants- defined by the Bay Area A Quality Management
uikt <' all new materials for inspection. Applicant understands and will comply with
No
1. °Y a •. /'� - all non-point source regulations.
Ilhave read the has mriols reyuirementi muhr'Cbspmr 6.95 of the
California Hcahh&Safety Code,Seen 25505,25533 and 25534,1 undersand that
if the building docs not cueeolly bove a tarot,tfin it is my responsibility to notify the
occupant of the requireinems must be mei poor to issuance of a Certificate of
Signature of Applicant Date
erorauthnmdagent Dine n lot Al] roof coverings to be Class "B" or better Ns
OFFICE