06100143 7777777777 717177. 777777777
CITY OF 11UPERTINO
BUILDING DIVISION PERMIT NFA_. '
BUILDING ADDRESS: AMCOL," ,SIGN COMPANY PERMIT NO. 06100143
PERMIT ISSUE DATE
OWNER'S NAME:
TECHCU 974
SANITARY NO. CONTROL NO.
)NE:
650858-122
ABUILDING PERMIT INFO
ARCHITECT/ENGINEER:
BLDG ELECT PLUMB MECH
O p LICENSED CONTRACTOR'S DECLARATION Job Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
Z with Section 7000)of Division 3 of the Business and Professions Code,and my license'
=y in full force and effect_ ILLUMINATING ELECTRICAL SIGN INDIVIDUAL LETTERS
License Cats Lam•
t tp Dare 1O Contracwr
'�� ARCHITECT'S DEC R N
a< 1 understand my plans shall be used as public records
t�U
,a
'u.y Licensed Professional
3 y--c OWNER-BUILDER DECLARATION
} I hereby affirm that I am exempt from the Contractors License Law for the
3 00 following reason.(Section 7031.5.Business and Professions Calc:Any city or county
which requires a pcmhit to construct,alter,improve,demolish,or repair any structure
-Z r prior k)its issuance,also requires the applicant for such permit to file a signed statement Ft.Floor Area Valuation
that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq
(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 lRWb%t: 0 0 Occupancy Type
not mote than five hundred dollars($500).
0 I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and die structure is not intended or offered for sale(Sex.7044,Business Required Inspections
and Professions Cafe:The Contractor's License Law does not apply to an owner of q p
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 or improve for purpose of
sale.).
0 1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License law.
0 I am exempt under Sec. B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
J I have and will maintain a Certificate of Consent to self-insurc for worker's compen-
sation,as provided for by Section 3710 of the labor Code,for the performance of the
work for which this permit is issued.
0 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 Worker's Compensation Insurance carrier and Policy number am:
Carrier. AM 04VIA&WeJC Policy No.4`—��1(e
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 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 Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
O CONSTRUCTION LENDING AGENCY
Fr I hereby affirm that there is a construction lending agency for the performance of
�. the work for which this permit is issued(Sec.3097,Civ.C.)
W Q Lender's Name
Z Lender's Address
V I certify that I have read this application and stale that the above information is
LL►-c correct.I agree to comply with all city and county ordinances and state laws relating to
0 V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless the City of Cupertino against
t.A liabilities,judgments•costs and expenses which may in any way accrue against said City
U 2 in consequence of the granting of this permit.
.� APPLICANT NDE NDS AND I OMPLY WITH ALL NON-POINT Issued by: Date
SOURC UL
00,
Re-roofs
re tcant/Con actor Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
ill 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
Cc&.Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0 Yeo
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which
..hit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
0 Yes to
1 have read the hazardous materials requirements under Chapter 6.95 of Uhc Califor-
nia Health&Safety Code,Sec' 25505,25533 and 25534.T undcrs d that if the building
does not Cli fly ve a a that i my responsibility I'y the occupant of the
rcyuircmcn nm /pri issa ofOccupan Signature of Applicant Date
All roof coverings to be Class"B"or better
OV�ncr or aAori7.cd agent Date