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11090094CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 10120 N DE ANZA BLVD OWNER'S NAME: ROMAN CATHOLIC WELFARE CORP OF SAN OWNER'S PHONE: 4082526441 ❑ LICENSED CONTRACTOR'S DcE�CLARATION License Class 6 --/Lic. # 7 �� Contractor °W D W Date r I hereby affirm that I am licensed carder the provisions of hapter 9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full force and effect. I hereby affirm under penalty of perjury one of the following two declarations: 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. APPLICANT CERTIFICATION 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. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulationsjer=fligCupertino Municipal Code, Section 9.18. Signature _- Date ❑ OWNER -BUILDER DECLARATION I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: 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 & Professions Code) I, as owner of the property, am exclusively contracting with licensed contractors to construct the project (Sec.7044, Business & Professions Code). I hereby affirm under penalty of perjury one of the following three declarations: 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. I have and will maintain Worker's Compensation Insurance, as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is issued. 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 Worker's Compensation laws of California. If, after making this certificate of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith comply with such provisions or this permit shall be deemed revoked. APPLICANT CERTIFICATION 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. (We) agree to save indemnify and keep harmless the City of Cupertino against liabilities, judgments, costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally, the applicant understands and will comply with all non -point source regulations per the Cupertino Municipal Code, Section 9.18. CONTRACTOR: MID WAY SIGNS PERMIT NO: It 090094 3290 BASSETT ST DATE ISSUED: 09/14/2011 SANTA CLARA, CA 95054 PHONE NO: (408)982-9696 BUILDING PERMIT INFO: BLDG ELECT r PLUMB' MECH F RESIDENTIAL r COMMERCIAL f— JOB DESCRIPTION: ST. JOSEPH CHURCH - CONSTRUCT NEW ILLUMINATED MONUMENT SIGN Sq. Ft Floor Area: I Valuation: $4900 APN Number: 31626097.00 1 Occupancy Type: PERMIT EXPIRES IF WORK IS NOT STARTED WITHIN 180 DAYS OF PERMIT ISSUANCE OR 180 DAYS FROM LAST CALLED INSPECTION. Issued by: Date: RE -ROOFS: 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 "A" OR BETTER HAZARDOUS MATERIALS DISCLOSURE I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use equipment or devices which emit hazardous air contaminants as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health & Safety Code, Sections 25505, 25533, and 25534. CONSTRUCTION LENDING AGENCY I hereby affirm that there is a constructionJI(ding agency for the performance of vmrk's for which this permit is issued 97, Civ C.) Lender's Name Lender's Address ARCHITECT'S DECLARATION I understand my plans shall be used as public records. Licensed Professional Signature Date CITY OF CUPERTINO V- M-9 I FEE ESTIMATOR - BUILDING DIVISION 19 ADDRESS: 10120 n. de anza blvd DATE: 09/14/2011 REVIEWED BY: bobs. APN: BP#: "VALUATION: 1$4,900 —� 'PERMIT TYPE: Building Permit PRIMARY Sign USE: g PENTAMATION 10EAP5 PERMIT TYPE: WORK construct new illuminated monument sign SCOPE SIGN TYPE FEE ID QTY SIGN FEE Ground Sign 1SIGNGR/RF 1 $327 TOTALS: $327.00 # Branch Circuits 1 $44.00 i.1r, :tl. r•:';%r,%( J`:'.... �'1%!iti,%. ��C'i7Ji< F''(': IESIGN Elec. Permit Fee: IEPERMIT Other Elec. Insp. 0.0 $44.00 W 'p . NOTE. This estimate does not include fees due to other Depts (i.e. Public Works, Sanitary Sewer District, School District, etc.). These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addn'l info. FEE ITEMS (I ee Resohrtion 11-053 E '. 7/UI I) FEE QTY/FEE MISC ITEMS Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00 Permit Fee: $327.00 Suppl. Insp. Fee:G Reg. 0 OT 0.0 hrs $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? Q Yes Q No $0.00 Sign Master Plan: 0 Yes Q No $0.00 Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: 1BSEISMICO $1.03 Select an Administrative Item Btdg Stds Commission Fee: IBCBSC $1.00 SUBTOTALS: $461.03 $0.00 TOTAL FEE: 1 $461.03 Revised: 09/02/2011 CITY OF CUPERTINO FEE ESTIMATOR - BUILDING DIVISION ADDRESS: 10120 n. de anza blvd DATE: 09/14/2011 REVIEWED BY: bobs. APN: I BP#: *VALUATION: 1$4,900 *'PERMIT TYPE: Building Permit PRIMARY Sign USE. PENTAMATION 1 CEAP5 PERMIT TYPE: WORK new illuminated monument sign �construct SCOPE SIGN TYPE FEE ID QTY SIGN FEE Ground Sign -1 1SIGNGR/RF 1 $327 TOTALS: 1 1 $327.00 1 # Branch Circuits 1 $44.00 IESIGN Elec. Permit Fee: IEPERA4IT 0"I'lev -,H,.�,j! Other Elec. Insp. L2.0j $44.00 NOTE. This estimate does not include fees due to otherDepts (i.e. Public Works, Sanitary Sewer District, School District, etc.). These tees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addnl info. FEE ITEMS (Fee Resolution 11-053 & 7111LI) FEE QTY/FEE MISC ITEMS Suppl. PC Fee: 0 Reg. 0 OT 1 0.0 hrs $0.00 Permit Fee: $327.00 Suppl. Insp. Fee: (F) Reg. 0 OT "00 hrs $0.00 PME Unit Fee: $44.00 PME Permit Fee: $44.00 Work Without Permit? 0 Yes E) No $0.00 Sign Master Plan: 0 Yes (j) No $0.00 Travel Documentation Fee: ITRAVDOC $44.00 Strong Motion Fee: IBSEISAffCO $1.03 Select an Administrative Item 1 Bldg Stds Commission Fee: IBCBSC $1.001 SUBTOTALS: $461.031 $0.001 TOTAL. FEE: 1 $461.03 Revised: 09/02/2011