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BUILDING DIVISION PERMIT
OWNER'S NAME:
ARCHIIEC (ENGINEER:
1 hereby affirm that 1 am licensed send provisions of Chapmr 9 (commencing
with Scotigqn 70(p)of Dtviaion3of Ne Buaines 'dProR.kWsCode,andmylicenseis
in full fortdWpQ9effacL ..
License CI G.•
I ti'M cad my plans shall he used as public records
Licensed Porem mal
OWNER -BUILDER DECLARATION
1 herehy affirm that 1 am exempt form the Contractor's License Law for the
fallowing moron. (Seedun 703 1.5, Business and Profeaatnaa Code: Any city or county
which mquires a Permit to construct, alter, improve, demolish, nr mlmtr any stmctum
prior At its issuance, atm requires the Applicant for such permit to file a signed sumanom
that he is licensed purmam to We pmvistm a Of the Contmcmr's License law (Chapter 9
(commencing with Section 70(0) of Division 3 of We Business and Professions Code) or
that he is exempt Wetefrom and We basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a Permit subjects We applicant to a civil penalty of
not mora than 0w hundred dollars (5500).
0 1, As owner of the property, or my employees with wages as Nair sole compensation,
will do We work and the sWctum is not intended maffered forte]. (Sec. 7094, Business
and Professions Code: The COntrutor'a License Law dans not apply to an owner of
property who builds at improves thereon, and whadoessueb work himaelforthrough his
awn employees, provided that such improvements are not Intended at offered formic. If.
however, We building or improvement is sold within one year of completion. We owmxr
builder will have the burden of proving that he did not build w improve for purpose of
0 1. as owner of We property, am exclusively contracting with licensed contracmra to
construct the pmjecl (Sec. 7094, Business and Professions L'mde:) The Contrumes Lt.
cense law does not apply 0 in Owner of property who builds or improves dmreon, and
who contracts for such projects with a convactor(s) licensed pursuant to We Contractor's
License Law.
O l am exempt under Sea .B&P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury One of the following declarations:
hew and will maintain aCer ificast of Cement to self-Insum for WmkcrS Compen.
.,tors, as Provided for by Section 3700 of the Labor Code, for We performance of We
work for which this Permit is issued.
0 1 have and will maintain Warkeh Compensation Insurance. as required by Section
3700 of We Labor Code, for the perfarmmce of We woh for which this permit is imued.
My Worker's Compensation Insurance carrier and Policy number art:
Carte $114 WA Policy No.: 601�O9T Y
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(Thissecdon need not becomplemd tithe perrokisforonc hundred dolhrs(5100)
or less.)
I certify that in to performance of the work for which this Permit is issued, I shall not
employ any person in any manner so As to become subject to We Workers' Compensation
Laws Of California. Dale
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject W the Worker's Compensation provisions of the [.be, Coda, you must
Forthwith comply with such provisions or this permil Mall W deemed rooked.
CONSTRUCTION LENDING AGENCY
I hereby affum than Were Is a construction lending agency for the perfummnce of
We work fur which this Permit is issued (Sec. 3097, Civ, C.)
Lender's Name
Lender's Addmm
I certify that I haw mad this application and state that We show information is
correct. 1 agree to comply with all city and county oMnamea and state laws misting to
building construction. and hereby authorise mpr,mmucto as of this city to enter upon We
above-mentioned property for inspection purposes.
(We) agree 0 saw, indemnify and keep harmless the City of Cupertino against
liabilities, judgments. costs and expenses which may in any way some, against said City
GOLDEN GATE SIGN CO
4050146
PERMITIa9UEDATE
Job Description
REVISION --IN HOUSE USE ONLY
NO NEW PERMIT ISSUED/ ORIG. #04040129
19310KIllystwell]
Required Inspections
WILL COMPLY WITH ALL NON -POINT I Issued by:
f - - TIAZARDOUS MATERIALS DISCLOSURE
Will We applicant or future building occupant store or handle hanrdous material
sed by the Cupertino Municipal Code, Chapter 9.12, and We Health and Safety
gection 25532(x)?
O Yea $No
Will the applicant or future building occupant use equipment or devices which
wardnus air contaminants as de0ncd by We Bay Area Air Quality Management
O Yes /VNo
that
dthatifthc building
We occupant of the
Re -roofs
Type of Roof
$e I]
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.
Signature of Applicant Date
All roof coverings to be Class "B" or better