09080419 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10310 S DE ANZA BLVD CONTRACTOR:TRUE NORTH SIGNS& PERMIT NO:09080419
GRAPHICS
C' 'FR'S NAME: CIVIC PARK CUPERTINO LLC
2277 CHANCERY CT DATE ISSUED:09/11/2009
SANTA ROSA,CA 95403 PHONE NO:(707)526-1908
Off._.c,R'S PHONE: 6503286230
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB
License Class C.tO! ic.# �oo� MECH r RESIDENTIAL r COMMERCIAL
Contractor ate
I hereby affirm that C ensed under the provisions of Chapter 9
JOB DESCRIPTION:INSTALL EIGHT(8)NON-ILLUMINATING SIGNS
(commencing with Sect 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 Sq,Ft Floor Area: Valuation:$12000
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by APN Number:36955999.CVCPK Occupancy Type:
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 PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Date:
granting of this permit. Additionally,the applicant understands and will comply Issued by .
with all non-point source regulatio s per the Cupertino Municipal Code,Section
9.18. �J ,
Sig---hare r`�// ,cam Date J1 RE-ROOFS:
_ All roofs shall be inspected prior to any roofing material being installed.if a roof is
ElOWNER-BUILDER DECLARATION installed without first obtaining an inspection,I agree to remove all new materials for
inspection.
I hereby affirm that I am exempt from the Contractor's License Law for one of Date:
the following two reasons: Signature of Applicant:
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, ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three I have read the hazardous materials requirements under Chapter 6.95 of the
declarations: California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain a Certificate of Consent to self-insure for Worker's compliance with the Cupertino
Municipal Code,Chapter 9.12 and the Health&
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety Code,Section 25532(a)should I store or handle hazardous material.
performance of the work for which this permit is issued.
Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
I have and will maintain Worker's Compensation Insurance,as provided for by maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Section 3700 of the Labor Code,for the performance of the work for which this Health&Safety Code,Sections 25505,25533,and 25534.
permit is issued.
I certify that in the performance of the work for which this permit is issued,I shall O t ed ens:
Date: 1�
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 CONSTRUCTION LENDING AGENCY
forthwith comply with such provisions or this permit shall be deemed revoked. I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued(Sec.3097,Civ C.)
APPLICANT CERTIFICATION Lender's Name
I certify that I have read this application and state that the above information is Lender's Address
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
ur a above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
ir, ify and keep harmless the City of Cupertino against liabilities,judgments, I understand m plans shall be used as public records.
costs,and expenses which may accrue against said City in consequence of the y
granting of this permit.Additionally,the applicant understands and will comply
with ail non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date