02100142 CITY OF CUPERTINO — -
BUILDING DIVISION PEROT CONTRACTOki4OR -ION::
BulL2I6e9I4mSTEVENS CREEK BLVD CAL-NEON SIGN PERMITNI021OO142
OwrgUERHE:ALLAN G AND MARIAN 1577 ALMADEN RD APPLICATIVIUM"2OO2
401 ONE: (408) 289-1883 SANITARY NO. // yy oo// CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
ad, l� 0
�aOo LICENSED CONTRACTOR'S DECLARATION hI,p� fDtl
€ Iheneby I)(D atL3lcenedandetproinef rChafer 9(commencing SIGNS--CHANNEL1oL1;'P alt
!-ow with Seain TIIDIB of Divisio Jof the Basin sand Pro(c;S�mCodg,mdmylamnse is
o. in full fo and of C// ''//��,,ll//JJ``
g(? Lkensc L' a
ON—' p Dam Contractor
ARCHITECT'S ATION
K I undersand my plans shall M used es ic records
d0
u3—.G Licensed P.Wmianal
OWNER-BUILDER DECLARATION
O� Y 1 hereby affirm Thai I am exempt from the Contraamea License law for the $1250
—0 o following reason.(Section 7031.5,Business and Professions Code:Any city or county
wg which requires a permit las construct,almr.improve,demolish,or repair any stratum
prior to its issuance.also requires the applicant for such permino file a signed statement
fi0that kislicensed pursuant tobeprovisions oftheConmaeor'sLicentaw(Chapter9 �.S�A�6At®A Valuation
SO
SO (commencing with Section r0(Xy of Qivision3 of NC Business and Professions Code)or
$ that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Nation 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of PN-N Occas ane e
not more than five hundred dollar(5500). 103 — UFE R Occupancy
�P
I,as owner of thep uperty,or my employes with wages as their Sole compensation.
will do the work,and the structure is not intended or offered for sale(Sec.IOsa,Business 104 — REBAR
and Professions Cotte:The Comvacmrs Liceve Law dm not apply to an Owner of 105 — ANCHOR 3ryV
R66UrIspeetions
property who Wildsor improves dereon,and whoduesauch work himself or through his t5 V LI 1 J
own employees,provided that Such improvements are not intended or offered rot tale.If. 304 — ROUGH ELECTRICAL
however the building or improvement is Sold within one year of completion,the owner. SOS — FINAL ELECTRICAL
builder will have the When of proving that he did not Wild or improve for purpose of
Sa'e.). 514 - FINAL PUBLIC WORKS
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.TOgq,Business and Professions Code:)The Contractor's Li. /
cone Law does not apply to an owner of property who Wilds or improve thereon,and
who contracts for such projects with a convacmm ac
r(s)licensed pursuant the Contractor's 4,1
License Law.
❑I am exempt under Sm. .B&P C for Nis reason I 1/
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby inn under penalty of perjury one of IM following declarations:
I have and will maintain a Cenifcam of Continuo self-insure for WorkerYCarten-
ion.as provided for by Section 37W of the Labor Code,for the performance or the
work for which this permit u issued.
❑1 hale and will maintain Worker's Compensation Insurance,AS retained by Section
3I00 of We Labor Code,for Ne pertotmance of the won for which this permit is issued.
Write urucecarrier 1'ynumbcf/yela3�-t�D
Poli No.:
CERTI IC EOF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
QBHmction need not bt,completed If the permit is parent,hundred dollars IS IWu
or Icve.)
1 unify that in the performance of She work for which this permit is issued,I shall not
employ any person in any manner an AS to become subject o the Workers'Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT.If,after making this Certificate of Exemption,you Should
become subject to She Worker's Compensation provisions of the labor Code,you must
OZ forthwith comply with such provisions or his permit shall bo deemed mvnkcd.
z CONSTRUCTION LENDING AGENCY
(-. Ihemby. irm Nn them iso construction lendinll,crty In,the perfmmanceof
(y ? the work for which this permit is issued(Sec.3097,Civ.C.) /Y
lel U Lender's Name
G 1Ondcls Address
U 0 T minify that 1 have read this application and sum that the above information is
D. F Corea 1 agree to comply with all city and county ordinances and sum laws relating in
Q U building construction and hereby authorise mpmsenutives of this city to enter upon the
W aheve-mentioned property for inspection purposes.
(We)agree to Save,indemnify and keep harmless Ne City of Cupertino against
rai liabilucs.pi gamma,comsand expenses w iah may in any wayace.against Said City
U z inconsequ nceo M antingofthistcrn'
APPLICANT STANDS AND\\�LL COMPLY WITH ALL I�ONP INT Issued by: Date
SOURCERE U
Ib - Re-roofs
signattye or p b rV CAW
�� HAZARDOUS MA RIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hemrdous material
AS defined by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safety
Cade.Section 35533(a)( All roofs shall be inspected prior to an roofing material being installed.❑Yea ONO
Will the applicant or future Wilding Occupant um equipment or device which If a roof is installe without first obtaining an inspection,I agree to remove
it hanrdous air cunuminanu as defined by We Bay Area Air Quality Management all new materi r Inspection.
victP
❑Ya ONO //YY
I have read to hanodoustrattrials requirements under Chapmr6.95 or Ne Califor
ria Health&Safe .Sections S,i3333 and333la.l undersand thazifthc Willing
d s t<unen am...L itis m ponsihilay m est cuant the
rC mens miss f Ccnificaao a/oc Signature pplicant Date
Owner or 4AInYzd agent m/4 All roof coverings to be Class "B"or better
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*CITY OF CUPERTIN(e f Z
«�
CITYOF
CUPEkTINO PERMIT APPLICATION FORM
N k 1 D Date: _ 3 . O-2-
Building
Building Address:
Owner's Name: Phone#:
42-6 -24'3?
Contractor: I _ O License#:
c2 3g S s
i
Contact: Phone #:
S4-,P—LLya1z -
ApplicandContractk �v
C� t 1"
Building Permit Info:
L
Bldg Elect Plumb Mech
Job Description: /' -
Residential: Commercial: * k 1,64g;
Sq.Ft. Floor Area: $/Sq.Ft.:
ArchilecUFngineer: t 1 Valuation: . 0
Type of Construction: Occupancy Group:
Qty. if
A2plicable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
y BREMSIGNS Rmdl Sings, Marquee ELECTRICAL
Ii
BUSLIC Business License BUILIDNG
8.3, ° �`