10030141 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20355 STEVENS CREEK BLVD CONTRACTOR:ACTIVE SIGN CO PERMIT NO: 10030141
OWNER'S NAME: WDV PROPERTIES I 1365 E TAYLOR ST DATE ISSUED:03242010
OWNER'S PHONE: 6507731135 I SAN JOSE,CA 95133 PHONE NO:(408)29766!0
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Classy r-X45 Lic.# 6 2 2 02
Contractor ACf�UC SreJins Date 3 '2y-ip MECNr RESIDENTIALr COMMERCIALr
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:CHANNEL LL rrER(ELECTRICAL)SIGN ON RACEWAY
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full farce and effect.
I herebyaffirm under penalty of perjury one of the following two declarations!: � 7s
I have and will maintain a certificate of consent to self-insure for Worker's �" `\
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. VIP .�/y^
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: yh' loutlp\an:$I
Section 3700 of the Labor Code,for the performance of the work for which this "(\�\ \ M\\ t
OA
permit is issued. APN Number:3162 0.2 355 Oelupancye
T p :
� J \ r
APPLICANT CERTIFICATION � ✓ �
I certify that I have read this application and state that the above information is
correct I agree 10 comply with all city and county ordinances and state laws relating F
to building construction,and hereby authorize representatives of this city to enter PERNH XPI 'I WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN I80rDAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments, W_'
costs,and expenses which may accrue against said City in consequence ofthe 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued b =Z°-(—YD
9.18. ////��//��// pp " y Date:
Signature J&Ag!_Ar '/ Date'3-24" /
i
❑ RE-ROOFS:
OW'NER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If roof is
hereby affirm that 1 em exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
i
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, Signature of Applicant: Date:
Business&Profusions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to I ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sce.1044,Business&Professions Code)..
1 hereby affirm under penalty of perjury one of the following three I IIA7.ARDOUS MATERIALS DISCLOSURE
declarations: ' I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth At
performance of the work for which this permit is issued. Safely Code,Section 25532(a)should 1 store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this I contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in my manner so as to become subject to the Worker'sOw a prized ent:
Compensation lawsof Califomia. If,after making this certificate of exemption
,I Date: 3-24-1,67
become subject to the Worker's Compensation provisions of the Labor Code,1 mush
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION I fpr which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state thal the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relating I
to building construction,and hereby authorize representatives of this city to enter j Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify'and keep harmless the City of Cupertino against Iiabilities,judgmenis,
costs,and expenses which may nceme against said City in consequence of the ARCIIITECI'•S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section (
9.18. I Licensed Professional
Signamre�.rup" Date 3'-24' '/O '
Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT I N O Fax: 408-777-3333
CONTRACTOR / SUBCONTRACTOR LIST
JOB ADDRESS: 26i35 :5 :s ': VC/1S C K PERMIT'# d ��
OWNER'S NAME: PHONE # -4UR 2f4 4
GENERAL CONTRACTOR: C1 VC i ✓1S BUSINESS LICENSE #
ADDRESS: q plv 51 —15A Pi o CITY/ZIPCODE:
*Our municipal code requires ah businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) NVILL BE- SCHEDULED UNTIL TIDE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CI'T'Y OF CUPERTINO
BUSINESS LICENSE.
am not using ani•subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information:
✓ SUBCONTRACTOR BUSINESS NAVE BUSINESS LICENSE #
Cabinets & Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring/Carpeting
Linoleum /Wood
Glass/Glazing
Heating
Insulation
Landscaping : L'
Lathing
Masonry
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature Date
D0301 4 L
Orr OF
CITY OF CUPERTINO
0
SIGN
CUPERTIN0 PERMIT APPLICATION FORM
APN# Date:
31 (OZ_ coq � • co � � Isi�olo
Building Address:
20`3 S-revens crepm 8ivd. CUperfino, ek
Mailing Address (if different from building address):
Owner's Name: Phone#:
Vain 'KLA G50-1-13_ I tab
Contractor: Phone#:
Ac.t��e. Stcj n zht,.
Fax #: uoa- 29�— o1 u3
Contractor License#: Cupertino Business License #:
�a2oa1
Contact: Phone #: LActa— Clio- 0L1g3
T. K, B'&& Fax #: i l08- 211- o'IU3
Building Permit Info:
Bldg ❑ Elect ❑ Monument ❑ Mounted on Building
Residential Commercial �—
Job Description:
CNannet l.elkei CEteckrtc2l) Slcjn ot) R3cz" .
Valuation (cost of project):
Project Size: Express ❑ Standard [" Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist& attach it to the
application or if applicable, include in plan set& the sheet index.
Revised 07/06/09