06050071CITY OF CUFLK> LN"
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
19507 STEVENS CREEK BLVD
OWNER'S NAME:
MENLO EQUITIES
ZONE:
ARCHITECffENGINEER:
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full Cotte and rrffe {, , , 1 � Le N ` _l
License Class G
Date LA Contractor
ARCHITECTS DECLARATION 0'ac t -f
1 understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
) hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to is issuance, also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than five hundred dollars (5500).
0 I, as owner of the property, or my employees with wages as their sole compensation,
will do the work and the structure is not intended or offered for salt (Sec. 7044, Business
and Professions Code: The Contractors License Law docs not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build oAmprove for plapose of,
sale.).'
0 I, as owner of the property, am exclusively contracting wilh licensed contractors - to
construct the project (Sec. 7044. Business and Professions C :) The Contractors Li.
cense Law docs not apply to an owner of property who build r improves thercon, and .
who contracts for such projects with a contractor(s) licensed rsuant to the Contractors
License law. B &fl {pyihis reason
0 I am exempt under Sec. _ a
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J 1 have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which Otis permit is issued.
0 1 have and will maintain Workers Compensation insurance, as required by Section
3700 of the labor Code, for the performance of the work for which this permit is issued
My Wor rs C�bmrance
r and Policy number arc:Carrier PollryNo.:V�0s�2
TION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the 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 the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Code. you must
Qforthwith comply with such provisions or this permit shall be deemed mvo .
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CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a consuuction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lenders Name
L.cndees Address
I certify that I have read this application and state that the above information is
correet. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
WEIDNER SIGNAGE
5001 24TH STREET
(916)452-8000
PERMIT NO. 060550071
PERMIT ISSUE DATE
SANITARY NO. CONTROL NO.
Job Description
BUILDING PERMIT INFO
ELECT PLUMB
1 DOUBLE FACED NON -ILLUMINATED MONUMENT SIGN
f �YSi�xctr�>/
1Nr
erre of AppltH
— or Dale
OUS MATERIALS DISCLOSURE
Will the apfuture building occupant store or handle hazardous material
asile d by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
0 Yes o
Will the applicant or future building occupant use equipment or devices which
.,nit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
0 yes
1 have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505.25533 and 25534.1 undemstand that if the building
docs not currently have a tenant, that it is my responsibility to notify the occupant of the
mauirmnenls which must be mel Wor to igsuance of a Certificate of Occupancy.
authorized
Date
Ft. Floor -Area
Required Inspections
I
l
S�
Issued by:
Re -roofs
Type of Roof
7400
Valuation
Occupancy
Date J_'
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