05030261 CITY OF CUPERTINO '�''
BUILDING DIVISION PERMIT ,CONTR •CTCZRYN�ORMATIN ''
BUILDING ADDRESS: PERMrr No. 5030261
ER'SNAME: PERMIT ISSUE DATE
PHONE: - SANITARY OL 10.
ARCHITEC fENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
1=3 E= t�
�°Lpo LICENSED CONTRACTOR'S DECLARATION Job Description
Z 1 Immanent Arm that l em Immaunder provisions of Chapter 9(commencing
with Secdon7")of Divislon7offt Buainetasand PrarcWMCode,a mYlkenmis
y
License
roe an b b SIGN l9 Lo, mr.t1fro Lk.N
te Dam a --martr CONTRACTOR: SIGN MAGIC
I U.i m s plane s
3 g
o essiow
y Linc -BUILDER DECLARATION
e!T1Intl As 1,m CFtmpl from the Contractors en,a IJw for Ne
o us mason.(Section 70313,Business and Profession Code:Any city or county
$Pi which requires a permit to construct,elan W prove.demolish,or repair any atroetum
FZy pilarmsl1ensedprsu pursuant
to the provisions
rofor Nem p= nes illsselLned Chap l=al
O that(commencing
eBusino/Wcenrelaw(Chepmr9 Sq.Ft. Floor Area /- Valuat 500
Ric (commenting wi hSatian 7000)of Division 7ofdeBuainess And Profession.Gnde)or
Nat be Is exempt thbodrom and die basis for the alleged exemption.Any vlolad' of '^-
Section 7071.5 by any applicant for a permit subjects me applicant to a civil penally of APN Number,!' �' / / 0ccdPanoy„hype
not mom than five hundlad dollen($SM. 1 - �rV' ./ll""--' .� r U L lr"— r
❑I.Mmw Of Nepapmy.mmyemployeuwiN"rA s irmie am rl m. 359h�o'f8 400. 1 /
will do the work•and dusstrllmum ts not intended&oBemd fmssk(Sec.70N,Butll {
I
and Profession Code:The Conummel License Law does not apply m An owner of quired,s_nsp ctiohs
properly who bulldsorimpntwhoome meon.and wdeer such wart himsulrm through his
ver Ff tf
awn employees.provided that such Improvements are not intended moffemd for rale.If. -
however,the Wilding or improvement is mid within aro year of ampledon,dee owner- /
builder will pave the burden of proving that he did not Wild or Improve for purywe of
ask.).
❑1,as owner of the property,am exclusively con arming with licensed conusctom to
conwet the project(Sec.7014,Business and Profeedoas Cade:)The Convector's Li-
came law does nal apply 0 an owner of property who Wilds ar improve dmman,end
who comets for such projects with a commanueU)licensed pursnnt to the Omm ctor.
Lkenu Law,
❑I Am exempt order See .B k P C fee thinerr reamed
Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one ofthe following declarations:
1 ham and will maintain a Cmifinm ofConsenl to ulbinum for Worker's Compen-
sec ion,As provided for by Section 7700 of the IJWr Code,for the performance of gee
work for which this permit is iuued.
El 1 have and will maintain Workefa Compewdan Ituu mon.As required by Section
7700 of the IeWr Code,for the performance of the wart for which this permit is iuued.
My Wor�kveh Compensation Issuance:carrier and Policy number Am:
Camimllp'� s.AFMid1s/Polity No.: t b$L�
CERn RFICA G 0 'AN FROM WORKER
COMPENSATION S
N ININSURANQE
(Thi mctim ncod not becompleted IfIW permit is Avow hundred dollars(SI M)
or kat.)
I cattily that In the performance of gm work for which this permit is Issued.I shall not
employ any penton in my mannerm As to become object to the Workeri Compensation
Laws of CalifnmlA.Dam
Applicant
NOTICE TO APPLICANT:IL arm,making mi C=nificam of Exemption,you should
We=subject On the Worker's Gampummon pmvilaM of IW IJWr Code.you mus,
00 forthwith comply wide such provisions m Ni M
permit Vbe mW l deereveled.
Z„0 CONSTRUCTION LENDING AOENCY
(-n I hereby Affirm Net mem is.commuctim lendingagemy for the perfrromme,of
ai> me wurk fur which this permit is blued(Sec.7097,Civ.C.)
W�Q tender's Name
z Lender's Address
U 1 cenify died 1 have mad this application and some ton dee above information is
LL r". carrecL 1 Agra in comply with all city and county ordinances and sok laws relating m
0`SJ' Wilding consunetion.and hereby authorize representatives of this city to ender upon dee
ts7 above-mentioned properly for inspection purposes.
(We)agme an an,indemnify and kap harmless the City of Cupertino Against
ccn Imbilides,judgments,costs and expenses which may in my way amue$Saint saidCity
U 7 in cuequene of dee gra
11- APPLICANr T s AND WILL L ITH ALL NON- INr Issued by: Date
SOU •GUbA ONS.
2 Re-roofs
re of Applican =mint Dam
OUS MATERIALS DISCLOSURE Type Of Roof
Applicant or future building acupantstom rehandle huardan mammal
;Dti.
efined by tW CupeNm Municipal Code.Chapter 9.12,and the Health and Safety
Section 75532()7 All roofs shall be inspected prior to any roofing material being installed.
❑YWIII the Applicant or Tatum Wilding=open,use equipment m devices whichaaIf a roof is installed without first obtaining an inspection,I agree to remove
hrdn eru denair camernins fined by me Bey Area Air Quality Management all new materials for inspection.
MO III���
C)Yes p6o
I have mad the hummOU3 mjgUJAU4AsVUmmQU1underChapter6.95oftheCalifor-
ni4Hc,ImASaletyCodc n 550515533ad .Iundcmwdmalifdn Wilding
does not cement) A in to to ihly to unity the occupant n me
mquimmen nch no u I'.Cenifiateo0ccu =y. Signature of Applicant Date
o xeaeg=est D, All roof coverings to be Class"B"or better