11080195 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10525 S DE ANZA BLVD(MAIN) CONTRACTOR:ABC DEANZA PLAZA PERMIT NO: 11080195
PARTNERS
OWNER'S NAME: ABC DEANZA PLAZA PARTNERS 870 MARKET ST STE 1257 DATE ISSUED:08/25/2011
'ER'S PHONE: 4082554100 SAN FRANCISCO,CA 94102 PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# r r
MECH RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:MELISSA ORCHID-INSTALL 1 ILLLUMINATED SIGN AT
(commencing with Section 7000)of Division 3 of the Business&Professions EXISTING STOREFRONT
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 Sq.Ft Floor Area: Valuation:$750
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APN Number:35918058.00 Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 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
9.18. Issued by- Date:
Signature Date
C i OWNER-BUILDER DECLARATION RE-ROOFS:
1 All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am 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,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&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. 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 any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or auth ized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must _ Date: '
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION l hereby affirm that there is a construction lending agency for the performance of wrk's
1 certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
i-Aemnify and keep harmless the City of Cupertino against liabilities,judgments,
,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
_.,ding of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
•C"� Licensed Professional
Signature Date �' G
(P(der -fqw (aa
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
(408)777-3228 • FAX(408)777-3333• building(cDcupertino.org
CUPERTINO
PROJECT ADDRESS v J �- �' %- /1 Y,,. C� T� L / APN
i % f I !� vE uJt7
OWNER NAME �iJ /r� i V �/1 PHONE j I} ` E
STREET ADDRESSJer CITY, STATE,-ZIP FAX
7 L-oVl C'
CONTACT NAME �? PHONE E-MALL _' l je�L _T_j
STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER ❑ OWNER AGENT CONTRACTOR ❑CONTRACTOR AGENT ❑ ARCHITECT ❑ENGINEER ❑ DEVELOPER / TENANT
CONTRACTOR NAME /' / LICENSE NUMBER y` LICENSE TYPE BUS.LIC
COMPANY NAMEi / L ., E MAIL 1 G1u�It�Ut LLE���G� �'✓� (^0w� FAX —
L1 c'
STREET ADDRESS ! J �, L i( ' / CITY.STATE,ZIP 'G�Y 1 ! l 0 S f C� S z PHONE
ARCHITECT/ENGINEERbNAME { LICENSE NUMBER ✓ / BUS.LIC I y[ OQ
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STA'L'E,ZIP PHONE
DESCRIPTION OF WORK (. 1 l` (� o V 1 C� L t ,{'V✓I. f�.'1%1
USE OF ❑ SFD or Duplex ❑ Multi-Family ILLUMINATED SIGN TYPE NO.OF SIGN AREA VALUATION
STRUCTURE: (Y/N) (S)
(CODE) SIGNS Hyl(SQ.FT.)
SIGN TYPE CODES: I LES a I I j 0,
B - BANNER SIGN M - MONUMENT(GROUND)SIGN
BL - BLADE SIGN P - PROJECTING SIGN
D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN T - TEMPORARY
E - ELECTRONIC �)- WALL SIGN
READERBOARD WI - WINDOW SIGN
TOTAL VALUATION:
By my signature below,I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
,application and the information I have provided is correct-, I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ordinances and state laws relating to buil co.nstme6n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: c
SUPPLEMENT FORMATION REQUIRED us -.
Site PlanBW
V 'MF° Y
_Elevations ❑^> Pltz s m �I $tI>�� c rrI %F
�: �_..tet
_Sign Details-including UL listing(s)applicable i 's� nAxD �� r��tslLvtrrx� 4
_Structural Calculations(if ;LAWW-
_Copy of Planning Approval Letter or Meeting with Planning prior toJow
submittal of Building Permit application. - _
SignApp_2011.doc revised 03/16/11
CITY OF CUPERTINO
FEE ESTIMATOR-BUILDING DIVISION
ADDRESS: 10525 s de anza blvd. DATE: 08/25/2011 REVIEWED BY: bobs.
APN: BP#: EVALUATION: $750 —�
PERMIT TYPE: Building Permit
PRIMARY PENTAMATION 1 CEAP5
USE: Sign PERMIT TYPE:
WORK install 1 illuminated sign at existinq storefront
SCOPE
SIGN TYPE FEE ID QTY SIGN FEE
Wall Sign,Electric 1SIGNWELEC 1 $260
TOTALS: $260.00
#Branch Circuits 1 1 $44.00
IESIGN Elec.Permit Fee: 1EPERMIT
LiOther Elea Insp. 0.0 $44.00
NOTE: Theseees are based on the preliminary information available and are only an estimate. Contact the De t or addh 7 info.
FEE ITEMS (1{ee Resolution 11-053 1i;tf. I-"11) FEE QTY/FEE MISC ITEMS
Suppl.PC Fee: E) Reg. 0 OT 0.0 hrs $0.00
Permit Fee: $260.00
Suppl. Insp.Fee4@ Reg. 0 OT 0.0 hrs $0.00
PME Unit Fee: $44.00
PME Permit Fee: $44.00
Sign Master Plan: Q Yes (F) No $0.00
Work Without Permit? 0 Yes 0 No $0.00
Travel Documentation Fee: ITRA VDOC $44.00
Strong Motion Fee: 1BSEISMICO $0.50 Select an Administrative Item
Bldg,S'tds Commission Fee: 1BCBSC $1.00
SUBTOTALS; $393.50 $0.00 TOTAL FEE: $393.50
Revised: 07/04/2011
OWNER-BUILDER DISCLOSURE FORM
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228- FAX(408)777-3333- building(a�cupertino.org
Dear Property Owner(s):
An application for a building permit has been submitted in your name listing yourself as the builder of the property
improvements specified at:
SITE ADDRESS �, �..�- �t /�YIZ 6\ 15 I V c APN
OWNER NAME l t✓�Z e I �'b 1 c l �l COY < OWNER ADDRESS
DESCRIPTION OF WORK: 11 t0, IVB tiu S 1�
We are providing you with an Owner-Builder Acknowledgment and Information Verification Form to make you aware of
your responsibilities and possible risk you may incur by having this permit issued in your name as the Owner-Builder. We
will not issue a building permit until you have read, initialed your understanding of each provision, signed, and
returned this form to us at our official address indicated. An agent of the owner cannot execute this notice unless
you, the property owner, obtain the prior approval of the permitting authority.
OWNER'S ACKNOWLEDGMENT AND VERIFICATION OF INFORMATION
(DIRECTIONS:Please read and initial each statement below to signify you understand or verify this information.)
V` ±1. 1 understand a frequent practice of unlicensed persons is to have the property owner obtain an "Owner-
Builder' building permit that erroneously implies that the property owner is providing his or her own labor and material
personally. I, as an Owner-Builder, may be held liable and subject to serious financial risk for any injuries sustained by
an unlicensed person and his or her employees while working on my property. My homeowner's insurance may not
provide coverage for those injuries. I am willfully acting as an Owner-Builder and am aware of the limits of my
insurance coverage for injuries to workers on my property.
lCG 2. 1 understand building permits are not required to be signed by property owners unless they are responsible for
the construction and are not hiring a licensed Contractor to assume this responsibility.
lC- (�3. I understand as an "Owner-Builder" I am the responsible party of record on the permit. I understand that I may
protect myself from potential financial risk by hiring a licensed Contractor and having the permit filed in his or her
name instead of my own.
t�4. 1 understand Contractors are required by law to be licensed and bonded in California and to list their license
numbers on permits and contracts.
5. 1 understand if I employ or otherwise engage any persons, other than California licensed Contractors, and the
totaPvalue of my construction is at least five hundred dollars ($500), including labor and materials, I may be
considered an "employer' under state and federal law.
6. 1 understand if I am considered an "employer" under state and federal law, I must register with the state and
federal government,withhold payroll taxes, provide workers' compensation disability insurance, and contribute to
unemployment compensation for each "employee." I also understand my failure to abide by these laws may subject
me to serious financial risk.
r,�_L7. I understand under California Contractors' State License Law, an Owner-Builder who builds single-family
residential structures cannot legally build them with the intent to offer them for sale, unless all work is performed by
licensed subcontractors and the number of structures does not exceed four within any calendar year, or all of the work
is performed under contract with a licensed general building Contractor.
�.� 8. 1 understand as an Owner-Builder if I sell the property for which this permit is issued, I may be held liable for
any'Financial or personal injuries sustained by any subsequent owner(s)that result from any latent construction
defects in the workmanship or materials.
OwnerBuilderFonn 2010.doc revised 04114/10
i(.C.1.9. 1 understand I may obtain more information regarding my obligations as an "employer"from the Internal
Revenue Service, the United States Small Business Administration,the California Department of Benefit Payments,
and the California Division of Industrial Accidents. I also understand I may contact the California Contractors' State
License Board (CSLB)at 1-800-321-CSLB (2752)or www.cslb.ca.gov for more information about licensed
contractors.
c�_L10. 1 am aware of and consent to an Owner-Builder building permit applied for in my name, and understand that
am the party legally and financially responsible for proposed construction activity at the site address listed above.
1<,C.111. 1 agree that, as the party legally and financially responsible for this proposed construction activity, I will abide
by all-applicable laws and requirements that govern Owner-Builders as well as employers.
�t12. 1 agree to notify the issuer of this form immediately of any additions, deletions, or changes to any of the
information I have provided on this form. Licensed contractors are regulated by laws designed to protect the public. If
you contract with someone who does not have a license, the Contractors' State License Board may be unable to
assist you with any financial loss you may sustain as a result of a complaint. Your only remedy against unlicensed
Contractors may be in civil court. It is also important for you to understand that if an unlicensed Contractor or
employee of that individual or firm is injured while working on your property, you may be held liable for damages. If
you obtain a permit as Owner-Builder and wish to hire Contractors, you will be responsible for verifying whether or not
those Contractors are properly licensed and the status of their workers' compensation insurance coverage.
CONSTRUCTION LENDING AGENCY
(DIRECTIONS:Please complete the following construction lending agency information.)
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.)
Lender Name: Lender Address:
Before a building permit can be issued,this form must be completed and signed by the property owner and
returned to the agency responsible for issuing the permit. Note:A copy of the property owner's driver's license,
form notarization, or other verification acceptable to the city may be required to be presented when the permit is issued
to verify the property owner's signature.
Property Owner's Signature: �,�' Date: l
------------------------------------------------=-------------------------------------------------------------------------------------------
(NOTE: The following Authorization Form is required to be completed by the property owner only when designating an
agent of the property owner to apply for a construction permit for the Owner-Builder).
AUTHORIZATION OF AGENT TO ACT ON PROPERTY OWNER'S BEHALF
Excluding the Notice to Property Owner, the execution of which I understand is my personal responsibility, I hereby
authorize the following person(s)to act as my agent(s)to apply for, sign, and file the documents necessary to obtain an
Owner-Builder Permit for my project.
Scope of Construction Project(or Description of Work):
Project Location or Address:
Name of Authorized Agent: Tel No
Address of Authorized Agent:
declare under penalty of perjury that I am the property owner for the address listed above and I personally filled out the
above information and certify its accuracy. Note:A copy of the property owner's driver's license, form notarization, or other
verification acceptable to the city may be required to be presented when the permit is issued to verify the property owner's
signature.
Property Owner's Signature: Date:
Ox,nerBuilderForm 2010.doc revised 04/14/10
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Certificate of Compliance (Sign Lighting) (Page 1 of 4) SLTGIC
Project Name: Ml-:1-1
,tl-:1-1 S, s /1 O a C H ` '1 Date:
Project Address: An:?-q D p 1� Al C ]? ? CA
106--D -9 g., � V y Z j2. l N a ?S'014
Locatio
'D14
Location of Sign L4 Outdoor Signs ❑Indoor Signs
Phase of Sign Construction ❑New Signs ❑Sign Alterations
Type of Lighting Control ❑New Lighting Controls ❑Replaced Lighting Controls ❑Not Installing Lighting Controls
This Certificate of Compliance includes the following components(check all that apply)
❑ Mandatory Measures(Lighting Controls) ❑ Maximum Allowed Lighting Power ❑ Specific Lighting Sources
1. Certificate of Compliance Declaration Statement(this may be a CIO.C45 or other eligible person)
I certify under penalty of pet jury,under the laws of the State of California,the infonnation provided on this form is true and
correct.
I am eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting design.
This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with
Title 24,Parts 1 and 6 of the California Code of Regulations.
71 The design features represented on this Certificate of Compliance are consistent with the information provided to document
this design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the
enforcement agency for approval with this building permit application.
Name: Signat4 �' 1.4 64 1 1
ure
Company: / Phone
e,,-FA� Pie51�5—w ye
Addres : r_ l +t License nmnber(may be contractor's lic#)
K� k t4
City/St to/Zip: Date
i L-2-
2. Installation Certificate(to be signed by responsible person after installation)
Permit number Checked by/Date
(Enforcement Agency Use (Enforcement Agency Use)
nstallation Declaration statement
I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and
Correct.
I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction.
I certify that the installed features,materials,components;or manufactured devices identified on this certificate confornis to all
applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the
enforcement agency.
I certify that the requirements detailed on this Certificate of Compliance have been met.
I will ensure that a completed,signed copy of this Installation Certificate shall be posted,or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the
building owner at occupancy.
Company Name: j/n�`)
Respo ible Person's Name: Responsibl7Pe! n'sSignature: -
License rUimber_(may be c ntractor's lic#1 Date gned: Position Company:
2008 Nonresidential Compliance Fornns October 2010
Certificate of Compliance (Sign Lighting) (Page 3 of 4) SLTG-1C
Project Name: Datc:
4. Maximum Allowed Lighting Power Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the maximum allowed lighting power method of compliance. (Complete part 5
of this Certificate of Compliance if there are signs using the Specific lighting sources method of corn liance)
A B C I D E I F G H I J
p Allowed Watts Design Complies?
w
Watts Y/N
� 5
.Zi > �O
D
.2 ia-� �\Wj'� ^N W it M vi
Ov � �?
wa C13
-0 COQ Q 3 M 4 2 Field
c _° a ii o u Inspector
X Check that
W ¢ •�W Q `—
o o U Sign
Description I— Complies
t✓ 't
N ` ❑
❑
° ❑
❑ ❑
❑ ❑
A Symbol or code used on the plans when plans are required)and other documents.
B A narrative description of the sign,or location of sign on the building,and the location of sign on construction documents.
OPTIONAL-Check this box only if this sign has a permanent,pre-printed,factory-installed,ENERGY VERIFIED label,confirming that
the sign complies with the Section 148 of the California 2008 Title 24,Part 6 Standards,using the Maximum Allowed Lighting Power
method of compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized
C by Underwriters Laboratories(UL)or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National
Standards Institute in accordance with ISO/IEC 17011.Surveillance by the Accredited Certification Body shall be an ongoing annual
inspection program carried out by a Type A Inspection body in accordance with ISO/IEC 17020. For signs with such an ENERGY
VERIFIED label,columns'D'through'I'are not required to be filled out.Note:Using an ENERGY VERIFIED label is an optional
method to validate compliance.An ENERGY VERIFIED label is not needed for compliance.
D The sign area in square feet.
E List"I"if the sign is internally illuminated. List"E"if the sign is externally illuminated.
F Allowed watts per square foot. Enter 12 if the sign is listed as"I"in column E.Enter 2.3 if sign is listed as"E"in column E.
G Multiply the square footage in column D times the allowed Lighthig Power Density(LPD=watts)in column F.
H Show the total installed watts in the sign,as determined according to the applicable provisions of§130(d or e).
I Enter Y if the number in column li is less than orequal to the number in column G. Otherwise,the sign does not comply.
J This page doubles as a field inspection checklist.
Field Inspector Notes:
2008 Nonresidential Compliance Forms October 2010
Certificate of Compliance (Sign Lighting) (Page 4 of 4) SLTG-1C
Project Name: Date:
5. Specific Lishtini! Source Method of Compliance
Certificate of Compliance and Field Inspection Energy Checklist
Complete this part if there are signs using the Specific lighting source method of compliance. (Complete part 4 of this
Certificate of Compliance if there are signs using the maximum allowed lighting power method of compliance)
A B C D E
OPTIONAL Field
Symbol ENERGY Specific light source used for Inspector
VERIFIED compliance Check that
or Description label Shall include only lighting
Code (see instructions technologies listed below Sign
below) List all that apply Complies
❑ ❑
A Symbol or code used on the plans when plans are required)and other documents.
B A narrative description of the sign,or location of sign on the building;and the location of sign on construction documents
C OPTIONAL-Check this box only if this sign has a permanent,pre-printed,factory-installed ENERGY VERIFIED label,confirming that
this sign complies with the Section 148 of the California 2008 Title 24,Part 6 Standards,using the Specific Lighting Source Method of
Compliance. The only labels that will be recognized for this purpose are ENERGY VERIFIED Certification Marks authorized by
Underwriters Laboratories(UL)or other Product Certification Body accredited to ISO/IEC Guide 65 by the American National Standards
Institute in accordance with ISO/IEC 17011.Surveillance by the Accredited Certification Body shall be an ongoing annual inspection
program carried out by a Type A Inspection body in accordance with ISO/IEC 17020.For signs with such an ENERGY VERIFIED label,
column'D'is not required to be filled out. Note:Using an ENERGY VERIFIED label is an optional method to validate compliance.An
ENERGY VERIFIED label is not needed for compliance.
Specific Light Source.Compliance Method. The sign(s)identified above use only the following lighting technologies:
List all applicable numbers 1 through 10 that apply in column D above for each row.
1 High pressure sodium lamps
2 Pulse start or ceramic metal halide lamps served by a ballast with >_88%efficiency
3 Pulse start metal halide lamps that are<320 watts,are not 250 watt or 175 watt lamps,and are served by a ballast
with>80%efficiency
4 Neon or cold cathode lamps with transformer or power supply efficiency>_ 75%with rated output current<50 mA
Neon or cold cathode lamps with transformer or ower supply efficiency>_68%with rated output current>50 mA
D Fluorescent lamps with a minimum color rendering index(CRI)of 80
6 (Note:when using electronic ballasts for compliance,lamps with a CRI<80 may be used)
7 Light emitting diodes(LEDs)with a power supply with> 80%efficiency
Single voltage LED external power supplies designed to convert 120 volt AC input into lower voltage DC or AC
8 output,having a nameplate output power less than or equal to 250 watts,and certified to the Energy Commission as
complying with the applicable requirements of the Appliance Efficiency Regulations(Title 20)
9 Compact fluorescent lamps that do not contain a medium screw base sockets(E24/E26)
10 Electronic ballasts with a fundamental output frequency>20 kHz
E This page doubles as a field inspection checklist.
Field Inspector Notes:
2008 Nonresidential Compliance Forms October 2010