10080107CITY OF CUPERTINO ]BUILDING PERMIT
BUILDING ADDRESS. 19505 STEVENS CREEK BLVD STE 102
OWNER'S NAME: LYN BAKERY
OWNER'S PHONE: 4089120998
LICENSED CONTRACTOR'S DECLARATION
License Class_ C ---4. C Lic.
Contractor _ G1 c it (
I hereby affirm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following two declarations:
1 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.
1 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. 1 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.
t
Signature Date
OWNER -BUILDER DECLARATION
I V affirm that 1 am exempt from the Contractor's License Law for one of
th. .dowing two reasons:
1, 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).
1 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
�erfonnance of the work for which this permit is issued.
;lave and will maintain Worker's Compensation Insurance, as provided for by
lection 3700 of the Labor Code, for the performance of the work for which this
uermit is issued.
certify that in the performance of the work for which this permit is issued, I shall
iot employ any person in any manner so as to become subject to the Worker's
,ompensation laws of California. If, after making this certificate of exemption, I
ecome subject to the Worker's Compensation provisions of the Labor Code, l must
_)rthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
certify that I have read this application and state that the above information is
orrect. 1 agree to comply with all city and county ordinances and state laws relating
building construction, and hereby authorize representatives of this city to enter
Pon the above mentioned property for inspection purposes. (Wej agree to save
demnify and keep harmless the City of Cupertino against liabilities, judgments,
)sts, and expenses which may accrue against said City in consequence of the
anting of this permit. Additionally, the applicant understands and will comply
ith air non -point source regulations per the Cupertino Municipal Code, Section
CON"RACTOR: A D & C DESIGN PERMIT NO: 10080107
2060 WARMSPRINGS CT APT 4 DATE ISSUED: 08/16/2010
FREb TONT, CA 94539 PHONE NO: (510) 625-9566
BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
�r
MECH, RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: LYN BAKERY - 19" HIGH ILLUMINATED LED SIGN
INSTA _LED ON BLDG
Sq. Ft I loor Area:
APN Number: 31649009.102
Valuation: $1250
Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
18) DAYS FROM LAST CALLED INSPECTION.
Issued 3Date:
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
inspectio i.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have re.ud the hazardous materials requirements under Chapter 6.95 of the
Californi a Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Cc de, Section 25532(a)!should I store or handle hazardous material.
Addition. illy, should I use equipment or devices which emit hazardous air
contamin ants as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner or authorized agent:
U _P ti
Date:—L—f Li
CONSTRUCTION LENDING AGENCY
I hereby a] firm that there is a construction lending agency for the performance of work's
for which i his permit is issued (Sec. 3097, Civ C.)
Lender's I4ame
Lender's i►ddress
ARCHITECT'S DECLARATION
understand my plans shall be used as public records.
gnature Date I Licensed Irofessional