15090200CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20803 STEVENS CREEK BLVD
CONTRACTOR: ALLEN SIGNS INC
PERMIT NO: 15090200
OWNER'S NAME: SAICH WAY STATION LLC
1982 STONE AVE
DATE ISSUED: 09/29/2015
PHONE: 4084534700
SAN JOSE, CA 95125
PHONE NO: (408)280-6500
,O,.WNER'S
Lal/LICENSED CONTRACTOR'S DECLARATION
JOB DESCRIPTION: RESIDENTIAL ❑ COMMERCIAL
License ClLie. #SIGN
T -MOBILE - STE # 105 - INSTALL (N) NON ELECTRIC
ON EXTERIOR WALL AND (N) MONUMENT SIGN
Contractor DateI
AwithSecti
F C.. .I hereby aee� sed nder the provisions of Chapter 9
(commenc7000) 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:
Sq. Ft Floor Area:
Valuation: $2500
1. 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
APN Number: 32632042.00
Occupancy Type:
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.
PERMIT EXPIRES IF WORK IS NOT STARTED "
APPLICANT CERTIFICATION
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
I certify that I have read this application and state that the above information is
180 DAYS FROM LAST CALLED INSPECTION.
correct. I agree to comply with all city and county ordinances and state laws relating
a
to building construction, and hereby authorize representatives of this city to enterTIALV)�Uw"O_
loop
upon the above mentioned property for inspection purposes. (We) agree to save
Issued by: Date: _TX4
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 gul tions pe�upertino Municipal Code Section 9.18.
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
Signature Date 7r i
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
the following two reasons:
1. 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
HAZARDOUS MATERIALS DISCLOSURE
sale (Sec.7044, Business & Professions Code)
I have read the hazardous materials requirements under Chapter 6.95 of the
2. 1, as owner of the property, am exclusively contracting with licensed contractors to
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
construct the project (Sec.7044, Business & Professions Code).
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
I hereby affirm under penalty of perjury one of the following three declarations:
Additionally, should I use equipment or devices which emit hazardous air
1. I have and will maintain a Certificate of Consent to self -insure for Worker's
contaminants as defined by the Bay Area Air Quality Management District I will
Compensation, as provided for by Section 3700 of the Labor Code, for the
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
performance of the work for which this permit is issued.
Health & Safety Code, Sections 25505, 25533, and 25534.
2. 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
Owne r u orize ngent:
_ Date: 2
permit is issued.
s. I certify that in the performance of the work for which this permit is issued, I shall
CONSTRUCTION LENDING AGENCY
not employ any person in any manner so as to become subject to the Worker's
I hereby affirm that there is construction lending agency for the performance of work's
Compensation laws of California. If, after making this certificate of exemption, I
a d (Sec. 3097, Civ C.)
for which this permit is issue
become subject to the Worker's Compensation provisions of the Labor Code, I
Lender's Name
must forthwith comply with such provisions or this permit shall be deemed
revoked.
Lender's Address
APPLICANT CERTIFICATION
ARCHITECT'S DECLARATION
I certify that I have read this application and state that the above information is
I understand my plans shall be used as public records.
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
Licensed Professional
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.
Signature Date
CITY OF CUPERTINO Ooqoax
FRF. FSTTMATnR _ RTITT ,DING' n1vrcTn1V
ADDRESS: 20803 Stevens Crk Blvd
FEE
DATE: 09/29/2015
REVIEWED BY: PAUL
APN: 326 32 042
BP#:
*VALUATION: 1$2,500
'PERMIT TYPE: Building Permit
hrs
P/ 4: ( 111 C 1 1'YI}t :
I
PRIMARY SignF
USE:
PENTAMATION
PERMIT TYPE: 1 CEAP i
WORK
T -MOBILE - STE # 105 - Install N
Non Electric Sign on Exterior Wall and N) Monument Sign
SCOPE
$0.00
SIGN TYPE FEE ID QTY SIGN FEE
Wall Sign, Electric 1SIGNWELEC 1 $286
TOTALS: $286.00
NOTE: This estimate does not include fees due to other Departments (4a Planning, Public Works, Fire, Sanitary Sewer District, School
Distract, etc . These ees are based on the prefimina in ormation available and are onl an estimate. Contact the De t or addn'l info.
FEE ITEMS (Fee Resolution 11-053 E, ff, 711/13)
FEE
QTY/FEE
MISC ITEMS
Plan(.'heck Fee:
Suppl. PC Fee: Reg. 0 OT
0.0
hrs
$0.00
tee
Permit Fee:
$286.00
Suppl. Insp. Fee:Q Reg. 0 OT
r0--0-
00
hrs
$0.00
PME Unit Fee:
$0.00
PME Permit Fee:
$0.00
const1wetion Tax:
Adm in i t'trat i ve .; ° t'. e:
Work Without Permit? O Yes (E) No
$0.00
Sign Master Plan: 0 Yes No
$0.00
i
Travel Documentation Fee: ITRAVDOC
$48.00
Strong Motion Fee: IBSEISMICO
$0.70
Select an Administrative Item
Bldg Stds Commission Fee: IBCBSC
$1.00
ST3BTTAL�
$335.70
$0 00`4TA FEE _
$335.70
Revised: 07/02/2015