05070013 (2) ,CITY OF CUPERTINO ��r>e�x�d +5" "�"• Vii'',
o BUILDING DIVISION PERMIT ��CQ1v=1'12AC�TU'Ii'[N 'OX2MATI01�1
G4:+-
auILDINaAODRFss: NORTHWEST SIGNS PPAMIT"cb5070013
0245 STT?.VP.Nq CREEK RT,Vn
W MIT NER'S NAME: PERISSUE DATE
COUNTRYWIDE HOME LOANS 120 ENCINAL STREET 07/01/2005
ONE: SANITARY NO, CONTROL NO.
(831) 469-8208
ARCHrIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION lob Descri h O ®® O l�
1 Imrchy,Moro that I m liceucd under provision,or Chapter 9(commencing p I /A
with Section 700)(1)of Division 3 of the Business and Profmiuu Code.and my Ilccow Is 'V�UAe
LED
mfaliface.ne c g:ry SIGN--ILLUM. CHAN. LETT. &
�a Dan }°I�com DOUBLE FACED SIGN CABINET
Dam 1 `°°DEro` )�- 2005
.. han ne3°ECblic wood,
]
1 understand my p....htll he uuJ u public recoNs •1—/
Sud
Licensed hereby ntl BU'D ®IN�
OWNER-BUILDER DECLARATION L
�0 Y I hereby alum that 1 1. exempt from the Contravenes o License law for tio,
i 00 following mason(Sectiondin F131.3.Business and Profesaiuu Code:MY city or county
which requires a pemh m uiro, et,alar,improv.a Permit t or ropy my mountain
duerncsl tstwnce.auumquirce drwismapplicant for inchmmum', rile.,signed statement
i < d mM ncinnwihScrummNepmvis on3of CBuMnorYlditf sio(Chapter Sq.Ft.Floor Area Valt*dUD700
re than eiscingwith Section70nd the basis for of tio,eged mandcal.miom Ction of
�
that k V av4npt therefrom and the butt for the alleged ewnptim.MY violation of
Section 7031.3 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mate thin live hundred dollam(M).
p 1,n owner of the pmpmy.w my employm withwages a melt mm mmpemdon. 31625043 . 00
willeo the work,and theincmre tsmtimended oroffered forsale(Sec.7044,Business
and Profeuncu Cade:The Commence,License Law dm not apply nc an owner or Required Inspections
prepeny who builds Lir I mpoews thereon,and who dm such work himse If or through his
own empleym,pmvided mal such improvements rte re tmeanded aro@red forsale.If,
however,the building or Improvement issold within one year of completion,the meet.
builder will have the burden of proving that he did not build or improv for purpose of
sale.).
Cl 1,as owner of the property.am exclusively contracting with licensed contractors in
construct the project(Sea 7041,Business and Professions Code:)The Commences I.I.
ceam
o menceall-
ceam Law dm not pply to an owner of property who Wilds or Improv Licence,and,
who contexts for such pmjecu with a contractor(s)licensed pursuant to Lie Conuacloes
License Law.
❑l am exempt under Sec. ,B k P C for this mason
Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury as of the following decimeters:
i haw and will malnuln•CenifiauofCavemu,elf-iuum for Worker's Compton.
n pmvided far by Section 3700 of tio,labor Code.for the Performance of the
work for which this permit is isrow.
❑1 Mw and will maintain Worker's Compensation Iuunna,as required by Section
3700 of the Labor Code,for the perform ma of the wake for which this permit is sued.
My Worker's Compeued�Iriannxpnrtier and Policy num�jW�r aCa�
Gniec 1�t/V I�J Policy No.: O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mix section need not W completed ifthe pemitls forane hundred dollen(SIO )
or um.)
1 certify that In the performance of the work for which this remelt is Issued,I shall not
employ any person in any manner an as to become abject to the Workers'Compensation
Law,of Callfernie Dau
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you mould
become subject in we Worker's Compensation provisions of the Labor Coda you muse
O foMwith comply with such provtsiou MW or this Permit all deemed rcwkcd.
Z CONSTRUCTION LENDING AGENCY -
[+ I Mmby affirm that them is construction lending agency for do,perfarmmce of
C4 tie work for which this Permit Is leaned(Sec.3097,Cin C.)
QUndoes Name
z Lovelace.Address
U 0' I modify mar 1 low read this application ane sou this de move information is
D.F corrin I apse he comply with all city and money ordinance, law relating b
C U building construction,and hereby authorice repmxnatime of this city to aur upon the
0. alcove-meetmW progeny for indemnify
keep hi
a (We)agree to crew indemnify and keep hamkv the City of Cupertino s agtlar
n„1A !abilities, enu,cmuand eapmua which may In any way accrue,against said City t
U^ APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINT Issued by: Date �'• "-OJ
ncoso� RECU TIO
-
Q, _4-/t I 0"S-- Re-roofs
){nature of I10ALCenne"Un Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building mcupam am a or handle hvardou material
u dented by me Cupertino Municipal Cade,C7mpur 9.12,and the Health and Safety
[Dorea Ko xss33(.>7 \ / All roofs shall be inspected prior to any roofing material being installed.
Y
Will the APPucmt or future Wilding occupant use equipment or device,which If a roof is installed without first obtaining an inspection,I agree to remove
I
t hm inow,tit cmuminmrs u defined by the Bay Amo Air Quality Management all new materials for inspection.
OYcs1haw mW theewlm&SafmyCadc,Savw33 Sa 125531.1undcoswd muifmc Wilding
,cum-itY haarananeiy uibilitY mnotifytheoncepmrofthei menu whkhm ora issu ofa cadnxamnfoccupsecy. Signature of Applicant Date
t All roof coverings to be Class"B"or better
Owner Lir littomed agent au
CITY OF CUPERTINO
®R SIGN
S
T
CUPFORM
PERMIT APPLICATION F
I� O O
APN# aI Z�5 ate:�2 DU�
Building Address: —7
Zo �\ c9 . 1, \ D c�
Owner's Name: w( Phone#:
Y O
Contractor: S Lc-,,fA-y)S License#:
Contact: Cupertino Business License#:
Building Permi nfo:
Blda Elect it
Job Description:Zy-% \ t Z ( t
Resid tial: ❑ Commercial:
Cost of Project /U Monument: Mounted on Building
Qty. if
Applicable Fee ID Fee Description Fee Group
BENERGY Energy BUILDING
BPERMFEE Bldg Permit Fees BUILDING
BPLANCHK Plan Check Fee BUILDING
BSEISMICOM Seismic Commercial BUILDING
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Sings, Marquee ELECTRICAL
BUSLIC Business License BUILDING
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