05030186 CITY OFCUPERTINO �alr-r+��a ^.+Eim �^' °
BUILDING DIVISION PERMIT _ ,COIRAG'�TURNIa$ Y2MATIO, Nh
BUILDING ADDRESS: HENRY' S DESIGN & SIGN CO ""'05030186
OWNER'S NAME: PERM]TIS'UHDATE
E; SANITARY O. i9kOL NO,
ARCHTIEC`FE GINEER: BUILDING PERMIT INFO
OEOPLUMB MOECN
YO00 LICENSEDCONIRACIOR'SDECLARATION Job Description
J I hereby affirm Nal 1 am licensed under proviaions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business and Profeulom Code.and my license Is
mull farce Acte effect SIGN--EXTER. MAUQUE 'SIGN
5 ZIj z uanea etre. Ix.P
Z.
F p Dam Contractor
ARCHITECTS DECLARATION
�i i understand my plus shall be used As public mcnNs
3��a Licenud Professional o _
p 3 Oat I am exempt
frond
DECLARATION
3�2 I Wreby affirm
that 1 am exempt from Ne Conwnar'A License 4w for the
O o fallowing mason.(Section 7031.5,Business and Professions Cade:Any city or rnunly
$(L which ro,dres A permit to ennsuuct.Wer,improve,demolish,or repair any structure XP
J fav it
prior in its!=name,also requires the applicant for such permit to file a signed sutemenl S �..
6s
that he is licensed pursuant to the provisions of the Contractor's Umns,Low(Chapter 9 Sq.Ft.Floor Area 1 �( F al6fiflo J
aE (commencing with Section 7000)of Division 3 of Ne Butlneuand Professions Code)or
s J Ll F � �f /
that he exempt therefrom and the bub for the alleged exemption.Any violation of *}� I FFF
Section 7031.5 by any applicant for A permit subjects the applicant In.civil penalty of 3 ft](11*10 0ObeupBnoy pe
Am more than five hon le d dollars($500).
❑1,As owner of the pmpmy,or my employees with wages As their sole compensation,
will W the work end the structure is not intended or offered for Ne(Sec.7044,Business
and ProfessCIA Cads:The Contractor's Lic me law does not apply to an owner of Required Inspections
property who builds or Improves thereon.and who doess tech wart himself or through his
own employers,pmvidW that such improvements arc vat intended CO offend!for sale.If.
however,
the building at Improvement is Mid within arc year of completion,the oweer-
Wlldef MB low uta burdm of proving Wt W did not bdW or union.far purpose of
uk.I.
❑1.as Owner of the propeity.am exclusively commuting with licensed mnuacurs to
Construct the p,oJm(Sm"1W,Business and Profusion Code:)The Contractor's U-
ceme Law docs not apply w in owner of property who Wilds or Improv thereon,Md,
who convects for such projects with ammus cuw(s)IlmnMd pursuant m the Commune.
License Law.
❑lam exempt under Seo ,B&P C for this towns
Owner �f/ Dau
WORKS C PENSATION DECLARATIONY
1 hereby affirm under penalty of perjury one of the following declarations:
❑I haw and will maintain aCeNficate.(Consent to selRlnaum for WorYSYsCompen.
Mtion,As provided for by SCCtion 3700 of the labor Code.fm the p Ofornmece of the
wort for which this pmn(I is issued.
❑1 haw and will maintain Worker's Compensation IuwMce,As required by Section
370D of the Labor Code.for site puformance olden work,for which this permit is sauced.
My Worker's Compensation Insurance carrier and Policy number em:
Calver. Paltry No,:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(rhs semdon need not becomplcwd lithe permit is fmonc hundred dollars(SIM)
or to$,)
I certify that in the performance of the work for which this permit Is issued.l shall not
empOymype in My manner M u to become subject to the Workers'Compensadon
U.S.rLassa of Cellfoto a. -
m p
NOTICE TO APPLICANT.lf.Ywrm CenlOeate of Exemption�ould
become subject to the Worker's Compensation provisions of the LAWr Code,you mus
.JO forthwith comply with such provisions or this permit shallW doomed revoked.
Z► CONSTRUCTION LENDING AGENCY
F+ I hereby aRrm Nat Nem isacouvuctinn lending agency fmlhe mrfmmamof
C> the work far which this permit s issued(Sm.3097.Civ,C.)
Cp Lender's Name
z L.Minea Add.
U0 I certify NM 1 haw read this application and Aute that the now information is
Uf E conal.1 agree to comply with all city And county Ordinances Md sum laws Misting m
C)SUbuilding construction,and hereby euNariM mpresenudws of Nis City m enter upon the
[i7 ahorc mentioned property for Inspection pmpML
(We)agree to use,indemnify and keep harmlm the City of Cupertino against
rp liabilities,fudgmems,cord and expenses which may in My way accrue against MidCity
U 7 In consequence of the grunting of this permit.
i7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATIONS.
54 3Z 3 Z / Re-roofs
Sigulurc ofAppli HAZARDOUS MATERIALS DISCLOSURE Da Type of Roof
Will thea Cupertino
or(Muni Wilding oaupMt atom mhad ft Heeds a mSuri)
u de0md by tite CupeNw Municipal Code.Chapter 9.13.MO IM Health and Safety
Cade,SCcuon 35533()1 All roofs shall be inspected prior to any roofing material being installed.
C]Yes C3 No
Will the applicant or fuum Wilding occupant use equipment Or devices which If a roof is installed without first obtaining an inspection,I agree to remove
I ' cmh hOINOUS It con aminam as defined by the Bey Area Air Quality Management all new materials for inspection.
District?
❑Yes El No
1 have robe the haeafdmismaterials requimmenu under Chapter 6.95 of theCalifor•
nia Health&Safety Cade,Section 255D5,35533 and 25534.1 undentand that if site Wilding
does not currently haw A uncal Nu It's my responsibility to notify the occupant of the
myuiremcnuwhiehmuatbemc p or issuanceyy�eNnea0ofampMpy.. Signature of Applicant Date
T1 z- 1 All roof coverings to be Class"B"or better
Owner or Authorized f9enl r' Da�