09010069 CITY OF CUPERTINO
BUILDING DIVISIONPER7�IIT COI'aR:AC''TORrtINFORMATIQNcr--
BUILDING ADDRESS: PERMIT NO.
10455 S DE ANZA BLVD TBD – TO BE D
OWNER'S NAME: PERMIT ISSUE DATE
PHOjk.QDIALP
S A CONTROL NO.
ARCHITECTIFNGINFML BUILDING PERMir INFO
BLDG ELECT PLUMB MECH
0
u o p LICENSED CONTRACTOR'S DECLARATION IOM Description
I hm Nans
hereby afnrt I am licensed under provisioof Chapter 9(rammencing P
with Svdon]IXYO.f Divicon 7 of Inn BtWneoand hofcstiom Calc.and my 1"Icons u
no. ;nm11formandert '7 f p INSTL 1 SET OF ILLUM WALL LTRS, RFACE EXTNG
I.mcrts Clu.Y �^ tic.r
n y,G
Date Conlraaar TENANT
7� aa ARCHfTECTS DECLARA
f1< I 1 n�.AyPlamahalWuedawbrertcaw PANLS IN MONNMT SIGN& INSTL RECVNG SIGN& HRS SIGN
'off LicvlsdPmrestianal **IMAGE NATIONAL, INC. PD BSL 1/15/09
3 OWNER-BUILDER DECLARATION
iE I btreby affirm than I am eacrept Ira.the COnoaera"Uccns Law far Ne
O 9 following moan:(Sued..70313,Business and Penfeasium Cade:Any city Or county
m which neutron a'omit Ineonsinet.alter,improve,demnilah,m repair any cinchonacinchonaySq.Ft.Floor Area Valuation
prior.iuisuari¢.also=quire,the applicant for such pes.il N file a signed aummat
< N,tneial;certontours.,mmNepm.is;an,orNecanlra=wral.iQns�w(wplm9
at (canmcming with Smiw 700M of Division 3 of the Business and Pmfeafom Code).
9 Nat he u esc.pt Nvefrom and Ne bud for dace alleged deception.Any violation of $6900
Sudon 7031.5 by any applicant ferr per=;t subjects be applicant to a cal penalty of APN Number Occupancy Type
not...son BK hundred dollars 1S500M 35917019 . 02
❑L u awrwa of circ pmpvry,.my wPlay=with aagu m Ne'v sole cvmpcwdon,
solo do Inc writ ma thcmwcturt Vnot inmMcd vartered forsale(Sa.TOu.Buri•... ns Required Inspections
e
and propulsions CedThe Contracmrs License Law d=trot apply le an Owner of q P
,W,on,who holds.,imp.vss Nmean.and who doessuch work huruelf or Waugh his
Own employ=,provided Nal such impmve.cots are not Intended t roatled fnrsale.If.
how,c,.the building.impm,,c Wot is sold within arc year of co splcuan,Ne awncr-
W;Idv NB case to bunch of pmvin0 that he did eat build Or improve far Pugme or
sale.M
❑L as owov of Inn property.aro eselmively contracting with B¢med contractors to
camwv the project(Sec 7054:Business and Pmfessiom Code:)The Coouacm-Ll-
c=ue Law Was out apply to an owner of property who,Wilds or impmws ft...and.
who contracts for such Projects with a contaelar(s)licensed pursuant to to Contractors
License Law.
❑1 cert aempt modes Sue .B d:P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I bveby anbm under pemltY of perjury We of to following deelaratims:
❑I h:ve and will maintain a CmiOole o/Conant th self-insurt f.W.kermCompco-
salon,u Mm ded for by Saxon 7700 of the IAor Code.for ted podur.men of the
work for which Nit permit is bound.
❑I have and will.aloin worker's Co.p=madan Insurance,as requirod by Sado.
7700 of Int La W,Code,for N=performance of the work for which Nis permit u issued.
My War sCamper�aatw htmrma vrtivPolity numhv art:
Gracie(. J 'Al' ]folic }.'a: 440',)l
CERTIFICATE OF EKEM PnON FROM WORKERS
COMPENSATION INSURANCE
(This aavan need Out W completed ifft pe reit Is Wore hundred dollar(5100)
Or less)
T certify Nat In the Mr...of Ne wart for which this Permit is Earned.)shall rat
..,my..y M mn in any mmncr,ser as to become subject to the Wertrn'Co.pmuadon
Laws of California.Date
Applin.,
NOTICE TO APPLICANT:If,after making this Cer ifiam Of E=connion.You should
become subject W Inc Worker's Compensation pmvisiom Of the Mbar Cale you muss
.�Z ranhwith comply with such pravidom.this Permit shall he dem.d revoked.
?O CONSTRUCTION LENDING AGENCY
[—i IhemhY affirm that thele is a construcdnn lending agency for the ptrforroan¢of
C the work far which Thu permit is babel(Sec X07.Civ,Q
yQ Lenders Nene
= Z Lemefs Address
U O 1 certify Our I bass.mad 01.application aro mule Nat the move information u
It,E comm 1 agree to comply with all city and county ordinances and cele laws minting no
.p Wilding consaucuon,and omby auNorine mpreseE of Nu city to enter upnn the
aWK-nmWWcd PmP=M1y for inap.tion pat ons,
Fc (We)all.I.sire indemnify,and keep bumlest Ore City u/Cupertino against
rn limilidm.judg.con.casu.rdespcoss which maythmY waYamaagainstsaid City
U Z in eans=q==of Ne granting of Nu p iL _�SJS
^ APPLICANT UNDERST DS AND WILL COMPLY WITH ALL NOry-POINT Issued by: Date
SOURCE REGUt:AT10N�^w.
I.CY> J.y 6�iS1o9 Re-roofs
Sign.tm of AppfianuConuactnr Dam —� —.
HAZARDOUS MATERSAIS DISCLOSURE Type of Roof
SYR dace applicant Or!dude Wilding amupant nom Or handle haamom masrial '
as denned by Ne Cupcnino Municipal Code.Chapter 9.11,and the Health and Safety
Cale.Schon 25572(a)?
❑Y.. All roofs shall be inspected prior to any roofing material being installed.
a
will ft applzmt Norm building occupant me wtip.al.dc.i=whine If a roof is installed without first obtaining an inspection,I agree to remove
emit haaaNnm air conuminmts as deftncd by f Bay Ara Air Quality M...Cement all new materials for inspection.
Dimm,7
❑Yes Xo
I hmerW dR hvaNwsnureriala mquTmnsnu under Ciupter6.95aft1eCalifor-
ras Health&Saf.yCo@,Secdam 75505.25533 and 21574.1 understand Institute building
Wes he C.mntly have a u.t.N.it is my responsibility to notify de c¢upam of NC
,equimmcna which mea rpgtodor m naw.yrco ora Ccrdfkam or Onvpanry. Signature of Applicant Date
Owner onuNoriadagent � I1�..M1' Dale' All roof coverings to be Class'."or better
Community Development
10300 Torre Avenue
Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
CUPEkTINO
Building De artment
JOB ADDRESS: PERMIT #
�45s &. O�tD 006 9
OWNER'S NAME: C' s I 00wtX (jPHONE # Z Q04,6W,
GENERAL CONTRACTOR: A�p�l_. ov� FAX #
I am not using any subcontractors: \X� ��° I t5 0
Signature Date
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing .
Flooring: Carpeting
Linoleum / Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor.Signature Date
CITY OF CUPERTINO
7 ITEMS OF 7 PERMIT RECEIPT OPERATOR: pdtg
COPY # 1
Sec : Twp: Rng: Sub: Blk: Lot :
APN . . . . . . . . : 35917019 . 02
DATE ISSUED. . . . . . . : 01/15/2009
RECEIPT # . . . . . . . . . : BS000006980
REFERENCE ID # . . . : 09010069
SITE ADDRESS . . . . . : 10455 S DE ANZA BLVD
SUBDIVISION . . . . . . .
CITY CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . .. RONALD CALI
ADDRESS . . . . . . . . . . : 10455 S DE ANZA BLVD
CITY/STATE/ZIP . : CUPERTINO, CA 95014
RECEIVED FROM . . . . : ALL SIGN SERVICES
CONTRACTOR . . . . . . . : TBD - TO BE DETERMINED LIC # 00096
COMPANY . . . . . . . . . . : TBD - TO BE DETERMINED
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . .
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
---------- ------------- --------- --- ---------- ---------- ----------
1BCBSC VALUATION 6, 900 . 00 1 . 00 0 . 00 1 . 00 0 . 00
lBSEISMICO VALUATION 6, 900 . 00 1 . 47 0 . 00 1 . 47 0 . 00
IBUSLIC FLAT RATE 1 . 00 114 . 00 0 . 00 114 . 00 0 . 00
IELCPLNCK HOURS 1 . 00 122 . 38 0 . 00 122 . 38 0 . 00
1EPERMITFE FLAT RATE 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1ESIGN UNITS 1 . 00 40 .79 0 . 00 40 . 79 0 . 00
1TRAVDOC FLAT RATE 1 . 00 40 . 79 0 . 00 40 . 79 0 . 00
------ ---------- ---------- ----------
TOTAL PERMIT 361 . 22 0 . 00 361 . 22 0 . 00
METHOD OF PAYMENT AMOUNT REFERENCE NUMBER
----------------- --------------- ----------
CHECK 361 . 22 #10491
---------------
TOTAL RECEIPT 361 . 22
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
-------- ---------------------------- -------- ----------------------------
101 FOUNDATION 103 UFER
104 REBAR 105 ANCHOR BOLTS
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
0�0/ 00 60 /
amlv�-
CITY OF CUPERTINO
SIGN
OF
CUPEkTINO PERMIT APPLICATION FORM
APN # Date:
25-q 1-7o i 9: 0,?,
Building Address: 10455 So. �2i�vlzcLg�Nd.
Mailing Address (if different from building address):
Owner's Name: Phone
�av�o�.� CnQI` Q2s� �QD �(04.46
Contractor: 1 _ Phone #: 'WDC)
�1ni0i �0�16na2 `1v�C,
vv Fax #:
Contractor License #: Cupertino Business License #:
700(o$b
Contact: Phone #: J&5 Ya-0— 6 444
AFax #:
Building Permit Info:
Bldg,K Elect Monument ❑ Mounted on Building ❑
Residential ❑ Commercial
Job Description:
uJa_&4us
�'-Q°i�- � �5�'^'''�� -I�ona,,,-1por„t,te �,�,, �vwr,u.,x,,.� sc�,•.
Valuation (cost of project): 4 / �D
Project Size: Express E9 Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & at it to the
application or if applicable, include in plan set &dhe sheet index.
evised 01/07/09