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CITY OF CUPERTINO
SIGN
COF
s CUPEVINO PERMIT APPLICATION FORM
APN # Date:
:�> � 9 - t-� - 0C) o0 �
Building Address: �, , E��k 131,V3 eA -z4/0 /(Z
Mailing Address (if different from building address):
Owner's Name: Phone #:
Contractor: Phone #:
Fax #:
Contractor License #: Cupertino Business License #:
Contact: Phone #:
Fax#: co 66-
Building
6Building Permit Info:
Bldg ❑ Elect 1!1-� Monument ❑ Mounted on Building
Residential Commercial
Job Description:
Valuation (cost ofprojectA- 1
Project Size: Express E—Standard ❑ Large ❑ Major ❑
Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the
application or if applicable,include in plan set& the sheet index. e::�—
Revised 01/07/09
I
CITY OF CUPERTINO
all"fic
SIGNI
CUEf�TINO FEESCHEDULE
,I
Quantity Fee ID Fee Description Fee Permit Type
Grou
f
1 SIGNDIRECT Directional B
1 SIGN/RF Ground/Roof/Projecting Signs B
f I SIGNMASCK Master Plan Sign Check B
1 SIGNREWRKG Rework of any existing Ground B
Sign
1 SIGNOTHER Other Sign B
1 SIGNREINSP Re-inspection Fee B
1 SIGNWNONEL Wall/Awning Sign, Non- B
Electric
1 SIGNWELEC Wall, Electric E
IESIGN Sign, Outline Lighting System E 10EAP5
llor Marquee supplied.from one
branch
IESIGNADD Additional Branch Circuit on E 10EAP6
Same Sign, Outline System or
Marquee
lELCPLNCK Plan Check Fee E
f PERMITFEE Electric Permit Fee E
j 1BCI3SC Cal Bldg Standards Commision B ALL PERMIT TYPES
Fee
,ZBSEISMICOM Seismic Commercial B
ZB
SETSMICRE Seismic Residential B
/ RAVDOC Travel &Documentation B
USLIC Business License B
CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21032 STEVENS CREEK BLVD CONTRACTOR:SUCCESS GRAPHIC SIGNS PERMIT NO:091 10095
OWNER'S NAME: CATHERINE CHEN 1744 QUEENS CROSSING DR DATE ISSUED: 11/17/2009
OWNER'S PHONE: 4088630000 SAN JOSE,CA 95132 PHONE NO:(408)306-9521
❑ LICENSED CONTRACTOR'S DECLARATION
6.10BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.# (P J
MECH RESIDENTIAL 4— COMMERCIAL
Contractor �Jtl-r"- � Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: INSTALL(I)INTERNALLY ILLUMINATED LED CHANNEL
(commencing with Section 7000)of Division 3 of the Business&Professions LETTER"STATE FARM"
Code and that my license is in full force and effect.
1 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.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area: Valuation:$2100
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. J
APN Number:36956001.00 Occupancy Type:
APPLICANT CERTIFICATION
1 certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point sour�rlations per the Cupertino Municipal Code,Section
9.18. C�! Vl ,�/ Issued b . Date: �/i�'0<
Signature Date '
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
1 certify that in the performance of the work for which this permit is issued,I shall Health&Safety Code :c7tiajks 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker'sCompensation laws of Califomia. If,after making this certificate of exemption,I Owner or authorizeA
become subject to the Worker's Compensation provisions of the Labor Code,I must "`•lY Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
1 certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. l agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date
y44 , Community Development
10300 Torre Avenue
tt '' Cupertino CA 95014
Telephone(408)777-3228
MY Of Fax(408)777-3333
CUPEI�TINO
Building Department
JOB ADDRESS: b C
(�� 5ST � CA
� S'' PERMIT# ?�
o � �
OWNER'S NAME: � PHONE #
GENERAL CONTRACTOR: (A, FAX #
I am not using any subcontractors:
Signature D to
Please check applicable subcontractors and complete the following information:
SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE #
Cabinets &Millwork
Cement Finishing
Electrical
Excavation
Fencing
Flooring: Carpeting
Linoleum/ Wood
Glass / Glazing
Heating
Insulation
Landscaping
Lathing
Masonry
Ornamental Sheet Metal
Painting/ Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
Owner/Contractor Signature 13ate