05050128BUILDING DIVISION PERMIT
ARCHITECnENGINEER:
1 hereby arfnnm mol I am licensed under provisions or Chapmr 9 iron
wide Section 7") of Division 3 ofrhe Business and Professions Code, and my
in full lane and eff u 7.y
License Class
Dama' Cdo,
51 "4' fwtRCHI'IECTSDECLA
I uncensored my plans coal be used as public rteords
OWNER -BUILDER DECLARATION
1 hereby afrom that I am exempt from the Conhamors License Law for the
following resume. (Section 7031.3, Buriness and Professions Cade: My city or county
which requires a pvmit to construct. alter. Impmve. demolbh, or repair any structure
prior m its issuance. also requires the applicant for such permit to file signed statement
Nat he Is Oeo¢d pursuant On the previsions or this Commutes License law (Chapter 9
(commencing with Section TODD) of Division 3 of me Business and Profession Code) or
that he is exempt therefrom and the basis fa the alleged memprloo. My violation of
Section 7031.5 by any applicant for a permit subjects me applicant m a civil penalty of
not mom than five hundred dolWn (M).
❑ 1, as co ner of the property, Or my employees with wages as tlwb sole cempmuadon,
will do the work, and the ssuctum is not intended or offered for sale (Sec. 70414. Business
and Profession Cade: The Contrnemes License Law does not apply In an owner of
property who builds or improv themon, and who does such work himself or through his
own employees, provided that such Improvements are not intended or offered manale, it.
however. the building or improvement Is sold within one year of completion• me owner.
Wilder will haw dm burden of proving Out W did anis Wild or improve fa purpose of
sal..).
❑ 1, as owner of me property, am =elusively contracting with licensed contractors m
canted me project (Sec. 7004, Rutins and Professions Code:) The Contractor's Li.
Corona Law does not apply to an owner of propeny.whe builds or improv memon. and
who contracts for such projects with acontncmr(s) licensed pursuant to the Cormamoes
License U.
❑ I am exempt under See. ,B&PC for this moon
Owner Data
'WORKERS COMPENSATION DECLARATION
1 hereby of on under penally of perjury, one of the following declandon
I have and will maintain Workers Compensation Insurance• as myulred by section
)0 of the labor Code; for the performance or the work for which this Permit Is intend.
flWWsemicareed wthecompleted ift a Penh W (oroac hundred dellan (5100)
or less.)
1 cenify that In the performance of the work for which this permit W issued. I Nall not
employ any person In any manners, as to become subject to the Workers' Compensation
Laws of Califomla. Data
Applicant
NOTICE TO APPLICANT: If. after making tela Codifies¢ of Exemption, you should
become object m the Worked Compensation previsions of the Lather code. you must
,J 0 forthwith comply with such provisions or this permit shall he deemed mvoked.
z tiCONSTRUCTION LENDING AGENCY
j -t I hereby alrtrm mat Dem its construction lending agency for the performance of
the work for which this permit Is Issued (Sea 3097. Civ. C.)
Wit Q Landers Name
z Lenders Addr=s
U O 1 aenify that I haw mad this application and sum this lite above information is
Bra V COMM I agree to comply with all city and county ordinances and sum laws misting in
O buildingconstruction. and hereby auuadm reprcsenutiv of this city to enter upon the
fsl ahove-mentioned property for inspection purposes.
(We) agree to law, indemnify and gasp harmless the City of Cupertino against
y liabiiities,judgmcnts, cents and expenses which may in any way acme against said City
U 7 in consequence of me pooling of this permit.,
F7
APPLICP1qT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
SOUR EGUL Ns.
s�0��s
g um,fMplicamIC,nuocmr Date
HAZARDOUS MATERIALS DISCLOSURE
Will me applicant or future building occupantsmre or bandle huallous material
as defined by the Cupertino Municipal Code, Chapter 9.17. and the Health and Safety
Cade, Section 255720?
` tDys R1u
Will the applicant or future building occupant use equipment or devices which
l Ina mus air conundrums at dc0ned by the Bay Area Air Quality Management
WEST COAST SIGN CO
SIGN --MONUMENT & WALL
Issued by:
Re -roofs
Type of Roof
11"'05050128
PERMITISSUE DATE
SANITARY j%5,12 C
uiN—W,11111 '
ti
• r • �4xi
Required Inspections
Date
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
all new materials for inspection.
❑Yes �lo //� y \/
Ihave alutyC hvSNtionsenal 2550,25533
sten ls ,255 3remcnuun@r Clupmr6m tofmc holding
Ire&Safctyhe.. Sectionsnhat It
my responsibility
understand oddly the
building
t/�� odic haw a meant. Net it is my responsibility lc notify tier pnn of me
titins whic��uOW met priorwiasuancc o(Y CcrtiOcamof upancy./ Signature of Applicant Date
�4 �/ — 7 G
All roof coverings to be Class "B" or better