B-2018-0484_PermitCITY OF CUP ERTINO BUILDING PERMIT
BUILDING ADDRESS: 19480 STEVENS CREEK BLVD CUPERTINO, CA 95014-2505 (375 01 014)
OWNER'S NAME: CALI ANNA MET AL
OWNER'S PHONE:
LICENSED CONTRACTOR'S DECLARATION
License Class C45 Uc. #834580
Co ntracto r ALLEN SIGNS INC Date 03/3 1/2020
I hereby affirm that I am licensed under t]1e provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business & Professions Code and that my license ls in full force and effe ct.
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. '· I have and will maintain Worker's Compensation Insurance, as prov ided for by f ( [,, Section 3700 of the Labor Code, for the performance of the work for which this
< "-permit is iss11ed.
AP£l1ICANT CERTIFICATI ON
I certify that I have read this application and state that the above inform ation is correct. I agree to comply with al! city and county ordinances
and state laws relating to bulldlng construction, and hereby authorize representatives of this city lo enter upon the above mentioned property for
inspection purposes. 0/Ve) agree to save inde mnify 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 wi ll comply with all non*point sou:ce regul
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pertlno Municipal Code, Section 9.18.
Signature �--·-Date 04/1 8/2018
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OWNER*RTJII,DER PECl ,ARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of 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 struc ture is not intended or offered for
sale (Sec.7044, Business & Professions Code) ' I, as owner of the property, am exc lusively contracting with licensed
contractors to construct the project (Scc.7044, Business & Professions Code).
I hereby affi rm under penalty of perjury one of the followtng three declarations:
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1 have and will maintain a Certificate of Consent to self*insure for Wol'ker 's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work fo r which this permit is issued. I have and will maintain Worke r's Compensation Insurance, as prov ided for by
Section 3700 of the Labor Code, for the performance of the work for which this
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 subj ect to the
Worker's Compensation laws of Cal ifornia. If, after making this certificate of
exemp tion, I become subject to the Worker 's Compensation provisions of the
Labor Code, i must fr nthwith comply with such provisions or this permit shall
be deemed revoked.
APPLICA NT CERTIFICATION I certify that I have read this application and state that the above Inform ation is correct. I agree to comply with all city and county ordinan ces and state laws relating to building construct!on, and hereby authorize representatives of this city
to enter upon the above mentioned property for inspection purposes. (We) agree
to save Indemnify and keep harmless the City of Cupertino against llabllltles, judgments, costs, and expenses which may accrue against said City In
consequence of the granting of this permit. Addit!onally, the applicant understa nds and will comply with all non*point source reg ulations per the Cupertino Mun icipal
Code, Section 9.18.
Signature Date 04 /1 8/20 18
CONTRACTOR: PERMIT NO: B-20 1 8-0484 ALLEN SIGNS !NC
SAN JOSE, CA 95 125
DATE ISSUED, 04/18/20 18
PHONE NO: (408) 280-6500
BUILDING PERMIT INFO:
)(BLDG -ELECT -PLUMB -MECH -RESIDENTIAL )( COMMERCIAL
JOB DESCRIPTION :
JIFFY LUBE · ADD (2) FLAT CUT OUT LETTERS, NON-
ILLUMINATED · (13.11 SF)
Sq. f,'t Floot' Area: Valuation: $300.00
APN Numbc1·: Occupancy Type:
375 01 014 A (Tenant Irnprovernents),A (Ten ant Irnprovcments),A
(Tenant lmprovements),A (Tenant lmprovements),A
(Ten ant lmprovements),A (Ten ant lmprovements),A (Tenant lrnprovements),A (Ten E1nt lmproveme n!s),A (Ten ant Irnprovements),A (Tenant Improvements),A
(Tenant Improvements)
PERMIT EXPIRES IF WORK IS NOT STARTED
WIT HIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAS T CALLED INSPECTION.
Issued by: Jasmine Archbold
Date: 04/18/20 18
RE*ROOFS:
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 malerials for inspection.
Signature of App licant: Date: 04/1 8/20 18
ALL ROOF COVERINGS TO RE CLASS 1tA11 OR BETTER
HAZARD OUS MATERI ALS DISCLOSURE
I have read the hazardous matcduls requirements under Chapte!' 6.95 of the Californ ia Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code1 Chnptcr 9.12 and the
Health & Safety Code, Section 25532(a) should I store or handle hazardous mnterlal, Acldltlonally, sho uld I use equipment or devices which emit hazal'dous atr contaminants as defined by the Bay Area Air Quality Munagement District I will maintain compliance with the Cupertino Municlpnl Code, Chapter 9.12 and the Health & Safety Code,
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� nnd 25534.
,._ -Owner or authorized agent: -.... Date: 04/1 8/20 18 =
CQNSIIHJCTIQ� LENDING AGENCY I h ereby affirm that the re is a construction lending agency for the performance of work's for which this permit is issued (Sec. 3097, Clv C.) Lender's Name
Lender's Address
ARCH IT ECI'S: D:ECLARAT ION I understand my plans shall be used as public records.