04030231 CI TY OF CUPERTINO
BUILDING DIVISION PERMIT G`aN.TRA.G'TUt TNI'C�Rivt�a�.TTUN -'
BmLDINC ADDRESS: PERMITNo.
ALLEN SIGNS INC 04030231
NEWS NAME: FERMITIS9URDATE
NE:
SANITARY OL NO.
ARCHITECTA3NGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUM0B 0MECH
0 0
_Op LICENSED CONTRACTOR'S DECLARATION
F'{ I hereby affirm that 1 the Iicevcd under provisions of Chapter 9 aommeming lob Description
w�S with Section 70(10)of Division 3 oldie Businaaand Professions Cade,and my license is FIN
� �� �
o mm M full force and cffec
Llcensec a�Lk.x SIGN--ILLUM. INDIV. CHANNEL LETTER
°am�ITECCI'o9 DECLARATION MAY 1Z 2004
y I understand my plans ahall be used as public records
30 Licensed Rofcssional BUILDING
Q OWNER-BUILDER DECLARATIONun
3<E 1 hereby..,. affirm that 11. exempt from the Canncmo Liccve Law far the
O O which
following son.Permit
t ]IBIS.Busitess and Ponove,demolish.
Code:Any city or caonly
$(v which requires a permit to construct,eine,imPmvx,demolish,nr repair any structure
•a y prior In its ioodam,also requires the applicant forsuch Permit to file a signed statement
Net w is licensed purauont to the provisions of the Contractor's Liconm Law(Chapter 9 Sq.Ft.Floor Area Valuat on
$ (commencing with Section 7000)of Division 3 of the Business and Professions Cow)or
that he is eadmpt Nerc(man and she basis for dw alleged exemption.Any violallon of
Section dent five
airy applicant fora permit subjects Ne appliant to a civil penalty of 3 MTTXp"er0 0 Occupancy Type
not more Nen five hundred delta.($50B.a per.
❑I,as owner of Ne property,or my employees with wages v Neirsole compensation,
will do the work and Neavuclure is notinwndedoraffemd Tarsale(Sec.70".Business
and Professions Code:The Coincides License Law does not apply w an owner of Required Inspections
property who hoods or tmpmeas feemon,end who doesauch work himself or through his
awn employers,provided Natsuch improvements are not intended oroRered forwle.if,
however.Ne building at improvement is mid within one year councilman.the owner.
builder will have the burden of proving that he did not build or hap ave for purpose of
sale.).
❑1.as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Commcmr's Li.
cave law does not apply to an owner of property,who builds or improves thereon.and.
who convects for such projects wife a communion)licensed pursuant to the Commences
License Law.
❑I am exempt uncer See B Q P C far thin ream.
nes Dale
W ORKEB'S COMPENSATION DECLARATION
1 hereby a(fiw under Nulty of perjury ons of Ne following declarations:
I have and will maintain a Ccaifiate of Consent to self-inaum far Warkeb Compen.
sation,at provided for by Section 3700 of the labor Code.for the performance of the
work for which this pewit is issued.
❑1 have and will maintain Wader's Compensation Insurance,as required by Section
3700 of the Labor Chile.for the performance of to work for which this pewit is issued.
My Worker's Compensation lmmmna carrier and Polity number ate:
Gnicr. v T Polity No.RO: V .
C T •ICA OF l PP0NPR0 —WOR ERS'
COMPENSA ON INSURANCE
(This section need native completed if the pewit is for enc hundred dollen(5100)
or las.)
I certify Nat in the perfowence of dic work for which this pewit Is issued,l shall not -
employ any person in any manner m as in become subject in the Workers''Compensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL after making this Cenificam of Exemption,you should
become subject to the Wod n's Compensation provisions of to labor Code,you must
QZ forthwith comply with inch provisions w this pewit shall Its deemed revoked.
r OCONSTRUCTION LENDING AGENCY
.�. I hereby affirm that Nem is a construction lending agency for the Performance of
ai 7the work far which this permit is issued(Sm.3097,Civ.CJ
W� Lenders Nam.
Q
6 Lender's Address
V Q 1 modify that 1 have mad this application and show Nat the above information is
contact.1 agree to comply with all city and county ordinances and stew haws relating to
0 building construction.and hereby auNorire representatives of Nis city to coca upon the
�E shove-mentioned progeny for inspection purposes.
(We)agree to save,indemnify and keep brandies the City of Cupertina against
f/y Ilabilides,judgmena,eosts and expenses which may In any way accrue agairsamid City
f,F7 in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL NON-POINT Issued by: Date
sou R GU IONS.
� �o� Re-roofs
Signature a(A plicanVConuectortiiibc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will are applicant or future building occupant store or handle havardous mawrial
v defined by Ne Cupertino Municipal Code,Chapter 9.12,and Ne Health and Safety -
odc.Schon 25532(.)1
[3y.[3y. Iy vvvNu All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment at dcvicu which If a roof is installed without first obtaining an inspection,I agree to remove
7dwarmearenty
t admitted,air mtamimmus at dclead by Nc Be,Arca Air Quality Management all new materials for inspection.
trict?
❑Yeas
1 have mail the hamNrwus mawrials requimmena undcrChapwr 6.95 of the Cadfor-
HcalN&S�fety Cndc,Smaov25505,25533and255M.lundcnteMthetiflM Wilding �2 G
haveawnan4thatitumymspomihilitymoodfytheoccupantofNc
uin i<hmu emetprianoiuvanccofe 0 cupancy. Signature q pp icant D to
o mama arzeaasent Date All roof coverings to be Class "B"or better
CITY OF CUPERTINO
BUILDING DIVISION PERMIS CQ)NTRACT��OR INTORMA'IY�,s
BUILDING ADDRESS: PERMIT NO.
ALLEN SIGNS INC 04030231
OWNER'S NAME: PERMITLSiUEDATE
PHONE:B SANITARY OLNO.
HITECTrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
n o o LICENSED CONTRACT'OR'S DECLARATION Job Description
inI hereby strum Net I am licensed under provisions of Chapter 9(commencing p
widtScelm.7(KXfi.f Division S of om Busimss and Pofasimm Code.and my liCcMC is
in full force and cffec ���®
bq1-mMsmGa,, �-4f+ L..,# SIGN--ILLUM. INDIV- E
z�,O Dem >F rgLa_ Contractor (..__
reqq t ARCHITECT-S DIECLARAT ON
y a 1 understand my plans shall he used u public records
.'mss Lianud Profcssionel .WtK x1001.
g S OWNER-BUILDER DECLARATION
I [ r
2 n g 1 hereby affirm on l 1. exempt from the f ontranoh License U.o far the
_O O following name.(Section]1131.5.Business and Pmfcssions Calc:Any city or county
a'n_� which requires a permit On eonsuum alter,improv.demolish,or repair any structure
r. prior to its issuance.also requires the applicant for such Permit to file a signed statement
si< that he is licensed pursuant m the provision of the Con(recoh License law(Chapter9 Sq.Ft. Floor Area aluat on
z�$ (commencing with Section 0000)a Division 3 ofthc Business and Profession Code)or
_ that bou exempt therefrom and the basis for the alleged exemption.Any violation of
Section 703 13 by any applicant far a permit subjects the appl¢ant In a civil penalty of 3�A 69'b.. gI70 p Occupancy Type
not more than,five hundred dollars(S500). Zig F1'�lY9'9
❑1,a owner of the pmpmsy,or my cmployea with wages as thnr sole campensauon,
will do the work end the,wctum Is not intended or o@sed far sale(Sec.70416,Business
and Professions Coxm
:The Coracmes License law does set apply to an owner of Required Inspections
property who builds or improve lhcreon.and who does such work himself or through his
own employees.provided th....Ch improvements am not intended.,offered!male It.
however.Ne building or improvement is sold within one year of completion.the owner.
builder will lave tine Wrdam of Moving that he did not Wild or improve for purpose of
sal.).
❑I,as owner or the progeny,am exclusively contracting with licensed eonuaeiors to
construct the project(Sec.706x.Business and Professions Code:)The Contractor's Li-
ana Law does not apply to as owner of property who Wilds car impove thcmon,and
who contracts for such projects with acanuaor(s)licensed pursuant o the Conuaoes
Laos.Law.
O l am exempt under See .B k P C for Nis moon
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury,arc of the following declarations:
I have and will maintain eCcnifiau,of Consent self-insure for Worker's Carri6er.a provided for by Sccuon 3]00 of the Labor Code,for the perfonnemc of the
Irk far which this permit is issued.
❑1 love and will maintain Worimes Compensation Insurance,as required by Section
3700 of the labor Code,for the porformarme of the work for which this permit is issued.
My Werker's Compensation Tnmmnce center and Policy number am:
Carrier. Orn(/1 Policy No.:/'Sv't-_AysU/tL/-t4
CF ('3j, OFE% Pf10N FR01.I'WO T
COMPENSATION INSURANCE
(Thu section need not he completed if the permit is forone hundred dollars($100)
Or hes)
I certify that in the purosmmtt of the work for which this Permit u issued,l shall not
employ any person in any manner an as in become subject m lW Workeri Compemauan
Law,of California.Dam
Applicant
NOTICE TO APPLICANT:Jr.after making this CCMIRCMC o(Exempdon,you should
become subject o the Worker's Compensation provisions of the Tabor Code,yaw most
.,Q foMwi0 Comply with such provisinn or this permit shall W deemed revoked.
'Z InCONSTRUCTION LENDING AGENCY
[-+� Iherebyaffirm this there is a Conswction lending tt,am,for the soficrm.of
tai tae work fon which this p.itis issued(Sec.309'1.Civ.C.)
Lal 0 larder's Name
Z Lender's Address
U0 I cenify that 1 haw red this application and warm this the shove information is
LL F correct 1 agree to comply with all city and county aminaatts and sate laws relating to
0U Wilding construction.and hereby authodrz mpreunativea of this city to enter upon the
amu' RWvo-mentioned Poperty(Of inspeelion Purposes
(We)agree to save,indemnify and keep harmless the City of Cupertino against —
r fa'A liabilities.judgments,costs and esp.which may in any wayaccoc against and City
U Z in consequence of the granting of this permit.
'--' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:S Date
SOUL{,EC REGULYp�T10N5. /
71.EX/A1crgM. L-�� �' a Re-roofs
Sig "phont/Coramactor ite _ ate
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fu um building occupant ruse or handle hazardous material
a defined by the Cupertino Municipal Code,Chapter 9.12,and site Health and Safety
Code,Sccuon 25533(x)1 All roofs shall be inspected prior to any roofing material being installed.
❑Yes k..
Will one applicam or Room building=open,tau equipment car devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Arca Air Quality Management all new materials for inspection.
suicst
❑Ya �Nu
1 havemad the ,Sado 25505,s5533mmcntsunder Chapter6 .Lirlthc Califon
nixs Outc&Safcty Code.Seaon3550A 1myresd15536.1 undersande m ilup Wilding �2 6
does not curtcn0y horde a tenant that it u my responsihility o wtil'y rbc acupant of the
reyu' a hichmu metprimu,IssuanccofaAl ��atof cupary. Signature O( ppicant Date
o eroraal orsdasem Dam '� All roof coverings to be Class ' or better
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
• COPY # 3
Sec : Twp: Rng : Sub: Blk: Lot :
APN . . . . . . . . : 31605052 . 00
DATE ISSUED. . . . . . . : 03/26/2004
RECEIPT # • . . . . . . . . : 24977
REFERENCE ID # . . . : 04030231
SITE ADDRESS . . . . . : 10831 N WOLFE RD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : BREAKTIME DESSERT
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, CA 95014-3548
RECEIVED FROM . . . . : KIMBERLY LIN
CONTRACTOR . . . . . . . : ALLEN LIN LIC # 22174
COMPANY ALLEN SIGNS INC
ADDRESS 1982 STONE AVE
CITY/STATE/ZIP . . . : SAN JOSE, CA 95129
TELEPHONE . . . . . . . . : (408) 280-6500
E ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
- - ---- ----- --- - --------- - ---------- - - - -- - ---- ---------- - ------- - -
BPERMFEE VALUATION 2 , 500 . 00 77 . 00 0 . 00 77 . 00 0 . 00
BPLANCHK PERMIT FEE 77 . 00 65 . 45 0 . 00 65 . 45 0 . 00
BENERGY PERMIT FEE 77 . 00 23 . 10 0 . 00 23 . 10 0 . 00
BREMSIGNAD NO. CIRCUITS 1 . 00 4 . 44 0 . 00 4 . 44 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BREMSIGNS NO SIGNS/MARQ 1 . 00 22 . 20 0 . 00 22 . 20 0 . 00
BSEISMICOM VALUATION 2 , 500 . 00 0 . 63 0 . 00 0 . 63 0 . 00
-------- -- ---------- --------- - ------ ----
TOTAL PERMIT 228 . 34 0 . 00 228 . 34 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
----------------- ------------ ---- --------------
OTHER 228 . 34 AMEX
TOTAL RECEIPT 228 . 34
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
191 FOUNDATION 103 UFER
104 REBAR 105 ANCHOR BOLTS
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
51.4 FINAL PUBLIC WORKS
•
l . CITY OF CUPERTINO
E SIGN 6 � " 3 Z3 '
D
OF
CUPERTINO PERMIT APPLICATION FORM
APN 316 Os— ��— �_ Date: 3
124
Building Address:
Owner'sNarrlg Phone#:
/� /
Contractor: License#:
I l 5-D 56ss
Contact: Phone#:
Applicant/Contract r: '
1!
Building Permit Info:
Bld lect Plumb Mech
lob Description:
S
Residential: ommerci
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation. I
(�7 ��
Type of Construction: _I Occupancy Uroctr
Qty. 'f
A able Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE— Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
J
MITFEE Elect Permit Issuance ELECTRICAL
SIGNAD Rmdl Si ns Add Branch ELECTRICAL
SIGNS Rmdl Si ns, Mar uee ELECTRICAL
C Business License BUILIDNG
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