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CITY OF CUPERTINO
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RrCTUR'+T1�1'ORMAO
BUILDING DIVISION PERMIT ,7C0-
BUILDING ADDRESS:
P"" N0. 0 6 0 2 014 2
21530 STEVENS CREEK BLVD
OWNER'S NAME:
PERMRLSSUEDATE
76 GAS STATION
05/25/2006
E:
SANITARY NO. CONTROL NO.
ARCHnECr/FNGINEEK:
BUILDING PERMIT INFO
"0
Q o 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby arnn "'C" em em licensed mater provisions of Chapter 9 (commencing
with Section 10M) of DlWsion 3 of the BusineuaM Profculum Code,snd my license W
inraItfmCCandsit
SIGN- -NEW SIGNAGE ON BUILDING, CANOPY &
I.kenmeane
FREESTANDING /INSTALL FASCIA ON CANOPY
Conti
Date 6— Canswar
ARCHr1ECl DECLA re
1 Understood my plans WII he used u public morsW
Licensed Professional
OWNER - BUILDER DECLARATION
1 b mby affirm that 1 am exempt from the Commutes License Law for the
following reran. (Section 7131.5, Business and Profesion Codc: Any city or county
which sequbm a permit to construct, ales. Improw, demolish, or repair any mumure
prior m its houence. Wu requires dmappliant for such permit to fiic.signed sommem
Uccom Law 9
Sq. Ft. Floor Area
VaIU a150��
Nat he W licensed pursuant a the provision of the Contractor's (Chapter
(commencing with Section 7000) of DiH ion 3 of she Dust. ud Prorneume Code) or
Net he is exempt slow( e", and the basis far she alleged exemption. Any violdon of
Section 7031.5 by any applicant fm a permit subjects the aPPliunt M • Civil penalty of
. �N [v��sslber
Occupancy Type
rat mare than five hundred dollars ($500).
3 S'] 2 0'Z" 7 0 0
0 1, as owner of tae property, or my employee, with wages as their sale compensation,
Required Inspections
9 P
will do the work and the wucture is not ntended or offered for sale (Sec. 70/4. Business
and Pmfessiaes Code- The Conemtor's Limn Law does WE apply N an owner of
property who builds W s or im prams thereon, and who does such work himsel f or through has
ownemplayene,provded Nusouhimpmwm aartmmtinsende4aro0kredfmaale IL
however, the building orimprowmant is mid within ore year "f compiction. the awner-
hu ms" win lave ae burden of prow "g that he did not Wild m impure fn purpose of
age.).
0 I, as owner of the property. am exclninly en acting with licensed enbaetma m
contmet the Perim (Sec. 70". Baines and Profession Code:) The Cnaaemfa U-
cc= Law done not apply to an owns of property who builds or improves then an. and,
.
who contracts for such pmjem with a comramr(s) licensed Ferment a the Camrmmr's
License haw.
0 l am aemp, untie see ,B k PC for NU memo
Owns Dam
WORKERS COMPENSATION DECLARATION
1 hereby a(nm under psWty a penury arc of the following declualimsc
haw and "I maintom a CWfiae of Cammd to self -Inure for Worker's Campn-
n, u provided for by Scotian 3700 of the Labs Coda, for the peR"marce of the
for which this permit is issued.
,
have and will maintain Wamkoex Compeemuon humane, u required by Section
73:7)00
,
of the Labor Core. far the performancoaf the work forwhich this In mil u leaned.
Worker's Compensatin W"mma center and Policy number m:
�'UVg7 Policy Na.: �fj�200
er.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
,
Crais section need not W: completed if see permit is farm hundred dolls. (S I M)
our less)
I cenify that In the performance of the work for which this permit u issued. I shall rat
employ any peen in any munerm as In become subject to the WorketY Compensation
Laws of Califomia. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Cniliae of &CO FIRM. you should
become subject to de Worker's Compermt provision of she Isbar Code. you muse
foMwith Comply with each pmvWlon or Nu permit hall be accred mowed.
CONSTRUCTION LENDING AGENCY
i
ns lending forth lerfarmemeof
1har Natmomuswnuec.
30 .)
> the walk fm whim Nis permit u wised (see. 3097, Civ. CJ
which
Lender's Name
'
LCMIZe Address
1 a ncify Nat I haw cad this application and me duce the above mformadn Is
comes, l agree to empty with all city and county milrances and sum laws mladng In
building construction, and hereby authon, mpresenuuws or this city to enter upon the
4 shove - mentioned property for Inspection purpous
L (WC) agree to sew, indemnify and keep harmless the City of Cupertino against
O liabilities , Judgments. cow and expenn which may in ray my acme against mid City
In consequence or the granting of this parmiL
APPLICANT ANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date
CtU�NND.ER
l� ?aa�Da—
Re -roofs ��-- -�
Type of Roof
so/
am
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding a Pantmmro s handle haurdon material
m defined by the Copenino Municipal Code. Chapter 9.13. and the Health and safety
Code, Sutton 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
0Yes ON.
If a roof is installed without first obtaining an inspection, I agree to remove
Will dm applicant s fume building aecupant use equipment or devices which
humorous air Contaminants u denmd by the Bay Ama Air Quality Management
all new materials for inspection.
rmL7
CYes —pw-
It
I bow end the hvaNnusmaterialsrtquirenw• . unde,ChmnM6.95 aftee Califor.
Hcalth&Safcty code, S omen, 25505.25533 uW25534.1 undxwuM thuiNe Wilding
rot cum "fly he a moue that It 4 my responsibility m ratify the occupant of the
a mlemmpdarmissuanmaface iromeorampemay.
Signature of Applicant Date
All roof coverings to be Class "B" or better
owners nixed scant Dam