08090039-EXPIRED CITE'OF CUPERTINO
BUILDING DIVISION PERMIT C-R?. iT CTOR. .NEI, R-M4T J01�1;:
BUILDING ADDRESS: PERMIT NO.
20560 TOWN CENTER LN MID WAY SIGNS 08090039
OWNER'S NAME: PERMIT ISSUE DATE
CIVIC PARK CUPERTINO, LLC 3290 BASSETT ST 09/09/2008
PHONE: SANUARY NO. CONTROL NO.
(408) 982-9696
ARCHPTECTIENGINEER: BUILDING PERMIT IN
BLDG ELECT PLUMB MECH
o p LICENSED CONTRACTOR'S DECLARATION
i U I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
:z tUu with Scetion 7000)of Divi on of the Bhainrss and Professions Code,and my license is 1 SET I LLMNI'/D CHNL LTRS & 1 (ONE)F LG MNT BLADE
r'y in full force and e L
z License Class L c.p ® SIGN NON—I LLMNT'D
E„ Dale Contractor
]-I'ECCS DECN -
j�< I understand my plans shall he used as public rccnr
)yU
w0 y Licensed Professional
OWNER-BUILDER DECLARATION
j< 1 hereby adTirm that I am exempt from the Contractors License Law for the
e p O following mason.(Section 703 1.5,Business and Professions Code:Any city or county
9 which requires a permit to construct,alder,improve,demolish,or repair any structure
y prior to its issuance,also requires the applicant for such permit to rile a signed statement
< that he is licensed pursuant to the provisions of the Contractor's License Law(Chaptcr9 Sq.Ft.Floor Area Valuation
tZ- (commencing with Section 7000)of Division 3 of the Business and Professions Code)or $2900
.. that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty ofNumber
not more than rive hundred dollars(5500). 3 6 9 5 5 0 8 1.� Occupancy Type
❑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
and Professions Code The Contractor's License Law docs not apply to an owner of Required Inspections
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner-
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li- .
cense Law docs not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractor's
License Law.
C]I am exempt under Sec ,B&P C for this reason
Owner Date
WORKER'S COMPENSATION DECLARATION
'I hereby affirm under penalty of perjury one of the following declarations:
❑I have and will maintain a Certificate of Consent to self-insum for Workers Compen-
sation,as provided for by Section 3700 of the Labor Code,,for the performance of the
work for which this permit is issued. z
❑I have and will maintain Worker's Compensation Insurance,as required by Section - '
3700 of the labor Code,Cor the ormance of the work for which this permit is issued
My Workers Com nsa' n in
cc carrier and Polity number am:
Carrier. ( Policy No.:/9!4W
—�CERTIFICAV OF EXEMP I ON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed if the permit is for one hundred dollars(SI00)
or less.)
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 Workers'Compensation
laws of California.Date
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
.� ,Z forthwith comply with such provisions or this permit shall be deemed revoked. -
'Z O CONSTRUCTION LENDING AGENCY
[� 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.C.)
W Q Lender's Name
2 Lenders Address
V 0 1 certify that 1 have read this application and state that the above information is
V. •"' correct I agree to comply with all city and county ordinances and state laws relating to
0V building construction,and hereby authorize representatives of this city to enter upon the
W above-mentioned property for inspection purposes.
a (We)agree to save,indemnify and keep harmless tic City of Cupertino against
rn liabilities,judgments,costs and expenses which may in any way accrue against said City
V Z in consequence of tie grant^ of this permit.
APPLICANT UNDERSTAN-S AND WILL COMPLY WITH ALL N .P INT Issued by: Date
SOURCMGUL 0
Re-roofs
M f p i UContractor Dato
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Code,Sc❑cyarsn25532(a)? o All roofs shall be inspected prior to any roofing
Will the applicant orrLurcmaterial being installed.
Will the applicant or tum blrilding occupant use equipment or dcvitxs which
If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as derined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes ",CO.
I have mad the hazard^s materials requirements under Chapter 6.95 of the Califor-
nia Health&Safety Code,Sections 25505,25533 and 25534.1 understand that if the building
does rudzuiready have a tenant th, it' my responsibility to notify the pant f the _
re mreI whi b met ri t issuance of a Certificate of tv
ry Signature of Applicant Date
Owner or au arized age Dam
All roof coverings to be Class'j `'or better
CITY OF CUPERTINO
�ara SIGN
CITY OF
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building�Address�ica_ot)
Maitre (if different from building address):
Owner's Name:_ Phone #:
Contractor: Phone #:
rn i���14 � ,
Contractor License #: Cupertino Business License #:
Contact: Phone #:
A ��(?K�
Building Permit Info:
Bldg Elect Monument ❑ Mounted on Building ❑
Residential ❑ Commercial ❑
Job Descriptio
Valuation (c st of proje9b
Project Size: Express [2' Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist& at it to the
application or if applicable,include in plan set& the sheet index.
Revised 6/16/08
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:-� CITY ®F CUPERTINO
.'i SIGN
CITY OF
CUPEKrINO FEE SCHEDULE
Quantity Fee ID Fee Description Fee Permit Type
Group
1 SIGNDIRECT Directional B
/ 1 SIGN/RF Ground/Roof/Projecting Signs B
1 SIGNMASCK Master Plan Sign Check B
1 SIGNREWRKG Rework of any existing Ground B
Sign
1 SIGNOTHER Other Sign B
I SIGNREINSP Re-inspection Fee B
1 SIGNWNONEL Wall/Awning Sign, Non- B
Electric
1 SIGNWELEC Wall, Electric .E
1ESIGN Sign, Outline Lighting System E 10EAP5
or Marquee supplied from one
branch '
IESIGNADD Additional Branch Circuit on E 10EAP6
Same Sign, Outline System or
Marquee
1 ELCPLNCK Plan Check Fee E
EPERMITFEE Electric Pen-nit Fee E
BSEISMICOM Seismic Commercial B
BSEISMICRE Seismic Residential B
TRAVDOC Travel &Documentation B
4 BUSLIC Business License B