07050054CITY OF CUPEKI'1.
BUILDING DIVISION
S CREEK BLVD I SUPERIOR ELECTRICAL
A RC H IT'ECf/E NG I NEER:
Z LICENSED CONTRACTORS DECLARATION
0
f hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70D0) of Division 3 of the Business and Professions Code, and my license is
Lu
a in full force and effect L' 7
z License Class Lic. N J
Contractor
ARCHITECTS DECLARA
a
I understand my plans shall be used as public records
U
Licensed Professional
n
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
o following reason. (Section 7031.5. Business and Professions Cale: Any city or county
ii 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 Llccnse Law (Chapter 9
in (commencing with Section 70D0) 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).
1700 WEST ANAHEIM ST
(562) 495-3808
PERMIT NO.
07050054
PERMIT ISSUE DATE
05/08/2007
SAMTARY NO. CONTROL NO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB
Job Description
INSTALL 3 SETS OF ILLUM LETTERS, ONE ON WALL, 2
ON
EXISTING MONUMENT SIGN
Sq. Ft. Floor Area
3261902 O'RbT Num
❑ 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 Contractors License Law does 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, site owner -
builder will have the burden of proving that he did not build or improve 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 Contractors U-
cense Law does not apply to an owner of property who builds or improves thereon, and
who contracts for such projects with a contractors) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under Sec , B de P C for this reason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby afllrm under penalty of perjury one of the following declarations:
❑ 1 have and will maintain aCertificate of Consent to self -insert for Workers Compen.
sation, is provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Instuance, as requited by Section
3700 of the Labor Code, for the performance of the work for which this permit is issued
My Worker C pe nMMlns raf carrier and Policy number are:
Cartier Ill tl4J( PolicyNo.:ll�—o[7
CERTI CATE OF EXEMPTION FROM WORKERS*
COMPENSATION INSURANCE
(this section need not be completed if the permit is for one hundred dollars (S 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
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O
r/1 CONSTRUCTION LENDING AGENCY
e-r 1 hereby affirm that there is q construction lending agcrrry for the performance of
>. the work for which this permit is issued (Sec. 3097, Civ. C.)
Q Lenders Name
z Lenders Address
Q 1 certify that I have read this application and state that the above information is
'—' correcL I agree to comply with all city and county ordinances and state laws relating to
Ubuilding construction, and hereby authorise represcntadi cs of this city to enter upon the
W above -mentioned property for inspection purposes.
CL (We) agree to save, indemnify and keep harmless the City of Cupertino against
rA liabilities, judgments, costs and expenses which may in any way accrue against said City
Z in consequence of the granting of this permit.
'—' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
SOURCE REGULA77q.n j
II ,,_7
Signature of Applicant/Contractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as deferred by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(a)7
❑ YesNo
Will the applicant or future building occupant use equipment or devices which
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District?
❑Yes *o
I have read the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code Sections 25505. 25533 and 25534.1 understand this if the building
does rat currently have a tenant. that it is my responsibility to notify the occupant of the
requirements which must faCcnfcaofcuyanyjor�ccJc
Owner or authorized agent Datc
Issued by:
Re -roofs
Type of Roof
$15800
Required Inspections
N
Occupancy "Type
Date
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