B-2016-3002it
CITY OF CUPERTINO BUILDING PERMIT
B UH> DINGADDRESS:
19459 STEVENS CREEK BLVD STE 110 CUPERTINO, CA 95014 (316 20 112)
CONTRACTOR:
AD & C DESIGN INC
PERMIT NO: B-2016-3002
FREMONT, CA 94539
OWNER'S NAME: MAIN STREET CUPERTINO
DATE ISSUED: 10/27/2016
OWNER'S PHONE; 408-777-3081
PHONE NO; (5 10) 625-9566
LICENSED COMRACTOR'S DECLARATION
BUILDING PERMIT INFO:
License Class ,C-45 Lic. #929828 .
Contractor AQ & C DESIGN INC Date 11/30/2017
XBLDG _ELECT _PLUMB
I her's;by affirm that I am licensed under the provisions of Chapter 9 (commencing
— MECH _ RESIDENTIAL X COMMERCIAL
with Section 7000) of Division 3 of the Business & Professions Code and that my
license is in full force and effect.
JOB DESCRIPTION:
I hereby affirm under penalty of perjury one of the following two declarations:
INSTALL ILLUMINATED WALL SIGN (1) - GOLDEN VISION
i. 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
'
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Sq. Ft Floor Area:
Valuation: $3200.00
APPLICANT CERTIFICATION
certify that I have read this application and state that the above
APN Number:
Occupancy Type:
information is correct. I agree to comply with all city and county ordinances
and state laws relating to building construction, and hereby authorize
316 20 112
representatives of this city to enter upon the above mentioned property for
ins p ction purposes. (We) agree to save indemnify keep harmless the
and
City Cupertino
If against liabilities, judgments, costs, and expenses which
PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting this permit.
Additionally, the applicant understands and will comply with all ll non -point
WITHIN 180 DAYS OF PERMIT' ISSUANCE OR
source e regulations per the Cupertino Municipal Code, Section 9.18.
180 DAYS FROM LAST CALLED INSPECTION.
Signature �/� Date 1012712016
r
Issued by: AbbyAyende
Date: 10/27/2016
OWNER -BUILDER DECLARAJION
I hereby affirm that I am exempt from the Contractor's License Law for one of the
RE -ROOFS:
following two reasons:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
i. I, as owner of the property, or my employees with wages as their sole
installed without first obtaining an inspection, I agree to remove all new materials for
� compensation, will do the work, and the structure is not intended or offered for
inspection.
sale (Sec.7044, Business & Professions Code)
$. I, as owner of the property, am exclusively contracting with licensed
Signature of Applicant:
contractors to construct the project (Sec.7044, Business & Professions Code)..
Date: 10/27/2016
I herby affirm under penalty of perjury -one of the following three declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
AT,i •ROOF COVERINGS TO BE CLASS "A" OR BETTER
- _I
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
HAZARDOUS MATERIALS DISCLOSURE
ry. I have and will maintain Worker's Compensation Insurance, as provided for by
I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700" of the Labor Code, for the performance of the work for which this
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
permit is issued.
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued, I
Health &Safety Code, Section 25532(a) should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the
material. Additionally, should I use equipment or devices which emit hazardous
Worker's Compensation laws of California. If, after making this certificate of
air contaminants as defined by the Bay Area Air Quality Management District I
will maintain compliance with the Cupertino Municipal: Code, Chapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the
the Health & Safety Code, Sections 25505, 25533, and 25534.
Labor Code, I must forthwith comply with such provisions or this permit shall
>
be deemed revoked.
w
g
Owner or authorized agent: 1
APPLICANT CERTIFICATION
Date: 10/27/2016
I certify that I have read this application and state that the above information is
CONSTRUCTION LENDING AGENCY
correct. I agree to comply with all city and county ordinances and state laws
1 hereby affirm that there is a construction lending agency for the performance
relating to building construction, and hereby authorize representatives of this city
of work's for which this permit is issued (Sec. 3097, Civ C.)
to enier upon the above mentioned property for inspection purposes. (We) agree
Lender's Name
to sage indemnify and keep harmless the City of Cupertino against liabilities,
judgTents, costs, and expenses which may accrue against said City in
Lender's Address
consequence of the granting of this permit. Additionally, the applicant understands
and ill comply with all non -point source regulations per the Cupertino Municipal.
ARCHITECT'S DECLARATION
Code;; Section 9.18.
1 understand my plans shall be used as public records.
Signature – Date 10/2712016
Licensed
Professional
S
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT • BUILDING DIVISION
10300 TORRE AVENUE • CUPERTINO,'CA 95014-3255
(408) 777-3228 • FAX (408) 777-3333 • building(ftupertino.org
ItUPERTINO
T ADDRESS � ®
APN #NAME
F
PHONE
E-MAIL
ADDRESS
i
CITY, STATE, ZIP
FAX
CONTACT NAMEPHONE
g� B
�y
E -MAIL
BX
STREET ADDRESS
CITY, STATE, ZIP
Ft
❑ OWNER ❑ OWNER -BUILDER ❑ OWNER AGENT Q CONTRACTOR ❑ CONTRACTOR AGENT ❑ ARCHITECT ❑ ENGINEER ❑ DEVELOPER ❑ TENANT
CO TRACTOR NAME ' (_
LICENSE NUMBERt � y `
�/]�A�fl.sC��/1.
LICENSE TZ, E J
BUS. LIC #
W
�1
COMPANY NAME � �-y �.,
E-MAIL
FAX
STREET ADDRESS p 9
CITY, STATE, ZIP "9r� ,,,, 9.'- s %j _,`
PHONE
ARCHITECT/ENGINEERNAME
LICENSE NUMBER
> fl 9
BUS. LIC #
COMPANY NAME {� � a � r
E-MAIL
FAX
STREET ADDRESS
CITY, STATE, ZIP
PHONE
DESCRIPTION OF WORK
USE,' OF ❑ SFD or Duplex ❑ Multi -Family
STRUCTURE: � Commercial
ILLUMINATED
(Y /N)
SIGN TYPE
(CODE)
NO.OF
SIGNS
SIGN AREA
(SQ. FT.)
VALUATION
($)
SIGN TYPE CODES:
B :- BANNER SIGN M - MONUMENT (GROUND) SIGN
BL - BLADE SIGN P - PROJECTING SIGN
D DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI`- DIRECTIONAL SIGN T - TEMPORARY
E+- ELECTRONIC W - WALL SIGN
READERBOARD WI - WINDOW SIGN
•�
[� -
F777D BY: _
TOT
By my signature below, I certify to each of the following: I am the property owner or authorized agent to act on the property owner's behalf. I have read this
application and the information I have provided is correct. I have read the Description of Work and verify it is accurate. I agree to comply with all applicable local
ord ances and state laws relating to building construction. I authorize representatives of Cupertino to enter the above -identified property for inspection purposes.
Si 'ature of Applicant/Agent: Date: f2 '`
SUPPLEMENTAL INFORMATION REQUIRED
Site Plan
Elevations
Sign Details - including UL listing(s) applicable
Structural Calculations (if applicable)
E Copy of Planning Approval Letter or Meeting with Planning prior to
i submittal of Building Permit application.
OFFICE USE ONLY
PLAN CHECK TYPE
ROUTING SLIP
❑ OVER-THE-COUNTER
❑ EXPRESS
❑ STANDARD
❑ LARGE
❑ MAJOR
WBUILDING PLAN REVIEW
'PLANNING PLAN REVIEW
❑ OTHER:
SignApp_2011.doc revised 03131111