14100070 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20200 LUCILLE AVE CONTRACTOR:PIERCE SIGNS& PERMIT NO: 14100070
DISPLAYS,INC.
OWNER'S NAME:
SAN JOSE,CA 95126 PHONE NO:(408)292-3500
LICENSED CONTRACTOR'S DECLARATION JOB DESCRIPTION:RESIDENTIAL COMMERCIAL
REMOVE 2(E)MONUMENT SIGNS&INSTALL TWO(2)(N)
License Class (��0 /D ZLic.# `� `� i� ILLUMINATED MONUMENT SIGNS
Contractor Date �� l
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.
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. Sq.Ft Floor Area: Valuation:$27000
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 APN Number:31602094 00 Occupancy Type:
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 IT 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 F ED 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
granting of this perm . Additionally,the applicant understands and will comply Iss
with all non-point u e reguI ti s per the Cupertino Municipal Code,Section
9 18.
RE-ROOFS:
Signature Date C) / 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.
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of Signature of Applicant: Date:
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 HAZARDOUS MATERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Health&Safety Code,Section 25532(a)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as definedM5505,25533,
ality Management District I
performance of the work for which this permit is issued. will maintain compliance wiipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sd 25534.Section 3700 of the Labor Code,for the performance of the work for which this Owner or authorized agent: Date:
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 CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
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 ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9 18.
Signature Date
CITY OF CUPERTINO
FEE ESTIMATOR— BUILDING DIVISION
ADDRESS: 20200 LUCILLE AVE DATE: 10/13/2014 REVIEWED BY: MELISSA
APN: 316 02 094 BP#: *VALUATION: 1$27,000
*PERMIT TYPE: Building Permit I'C i N CHECK
PRIMARY Sig n PENTAMATION 10EAP5
USE: PERMIT TYPE:
WORK REMOVE 2 E MONUMENT SIGNS & INSTALL TWO 2 N ILLUMINATED MONUMENT SIGNS
SCOPE
SIGN TYPE FEE ID QTY SIGN FEE
Ground Sign 1SIGNGR/RF 2 $718
TOTALS: $718.00 Mv"M _
r _ r
MYMISF '32,
71
111ifrttb.I'lura Check #Branch Circuits 1 $48.00
fFj I fa sI I, Num Ilerm. Vit, IESIGN Elec.Permit Fee: IEPERMIT
01her Plur b InspOther Elec.Insp. 0.0 $48.00
NOTE:This estimate does not include fees due to other Departments(i.e.Planning,Public Works,Fire,Sanitary Sewer District,School
District,etc. . These ees are based on therelimina information available and are only an estimate. Contact the Dept./or addn'l info.
FEE ITEMS (Fee Resolution 11-053 Eff. 7/1/131 FEE QTY/FEE MISC ITEMS
,166 t Chuef: Rr,ce
Suppl. PC Fee: 0 Reg. 0 OT 0.0 1 hrs $0.00
Permit Fee: $718.00
Suppl. Insp.Fee:(a Reg. 0 OT FO.01 hrs $0.00
PME Unit Fee: $48.00
PME Permit Fee: $48.00
(.'onslruclion Tax.,
f4drt ini,�rrafive free:
Work Without Permit? O Yes No $0.00
Sign Master Plan: 0 Yes (E) No $0.00
Travel Documentation Fee: ITR.4VDOC $48.00
Strang Motion Fee: IBSEISMICO $7.56 Select an Administrative Item
Bldg Stds Commission Fee IBCBSC $2.00
} $871.56 $0.00 TOTAL FEE: $871.56
Revised: 07/10/2014