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CITY OF C;UFEKI1NU
BUILDING DIVISION PERMIT
PERMIT NO.
BUILDING ADDRESS:
19748 STEVENS CREEK BLVD TBD - TJ BE DETERMINED 07090081
PERMIT ISSUE DATE
OWNER'S NAME:
SOUTH BAY INVESTMENT GROUP _
NE:
ARCHITECT/ENGINEER:
LICENSED CONTRACIUK b LJPI-L+Knr I ry
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 force and effect.
License Class Lle• N
Date Contractor
ARCHITECTS DECLARATION
1 understand my plans shall he used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I 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• impmvc, demolish, or repair any structure
prior to its 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).
❑ 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 sale (Sec. 7044, Business
and Professions Code: The Contractor's License Law does not apply 10 an owner of
property who builds of 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 or improve for purpose of
sale.).
. as owner of}, property, am exclusively contracting with licensed contractors to
o tvct the pro.it Z. 7 14, Business and Professions Code:) The Conaactoes U.
cense Law d m apply td alt owner of property who builds or improves thereon, and
who contracts ruch projdcts with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ l am ext S B& P C for n
Owner` Daw_q
WOR S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ I have and will maintain Worker's Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number are:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION 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 th performantc of the work for which this permit' issued. I shall not
employ any pe in matjlucr as to be sub' W r rs' Compensation
Laws of Calif
Applicant
NOTICE TO�PP C If, a ter making this cm tcae o eruption, you shauW
become subj t to the W leer's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby alum that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have read this application and state that the above information is
correct. 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.
(Wc) ague o save, indemnify and keep hamrlcss the City of Cupertino against
liabilities, judpm ts, costs aAd expenses which may in any way accrue against said City
in consequen c the gran g of this permit.
APPLICA NDE DS AND WILL COMPLY WITH ALL N/ON-POI
SOURCE
Signature AppliU ntractor (� DAe
H RDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code, Section 25532(a)?
❑ Yes / N
Will the applicant of future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes NPIC
have read the hats xu materials requirements under Chapter 6.95 of dtc Califor-
nia H alth & Safety C , Sections 25505, 25533 and 25534.1 understand that if the building
d not cu ably ha pant. that it is my responsibility to notify the occuppt of the
req i nor to issuance of a Certi ale o ygruc •P
✓ _/`
O mer or autharired agent Date
SANITARY NO. CONTROL NO.
BUILDING PERMIT INFO
ELECT PLUMB
Job Description
INSTALLING ILLUMINATED CAHNNEL LETTERS AT STORE
FRONT.
Sq. Ft. Floor Area $3000 Valuation
3690600 9` W Number Occupancy Type
Required Inspections
Issued b)
Re -roofs
Type of Roof
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 r.laterials for inspection.
Signaturc of Applicant Date
All roof coverings to be Class "B or better