11120118 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19060 STEVENS CREEK BLVD CONTRACTOR:HENRY'S DESIGN& PERNHT NO: 11120118
SIGN CO
ONN'NER'S NAME: UNITED POLARIS INC 2018 EVANS LN DATE ISSUED: 12/22/2011
OWNER'S PHONE: 4089058798 SAN JOSE, CA 95125 PHONE NO:(408)269-0888
❑ LICENSED CONTRACTOR'S DECLARATION F, F
BUILDING PERN4IT INFO: BLDG ELECT PLUMB
License Class C `~ Lie.# l ) f.._.
NIECH RESIDENTIAL CON4N4ERCIAL
Contractor,2 O AJ �� Date /` �—
JOB DESCRIPTION: MICHELLE'S PANCAKE HOUSE-INSTALL ILLUMNINATED
I hereby affirm that I am licensed under the provisions of Chapter 9 CHANNEL LET'T'ER SIGN
(commencing with Section 7000)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:
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. Sq.Ft Floor Area: Valuation:$4000
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 APN Number:37507046.19060 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
Date:
granting of this permit. Additionally,the applicant understands and will comply Issued b�� � `"
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18,
RE-ROOFS:
Signatur Date t All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,1 agree to remove all new materials for
inspection.
❑ ONN'NER-BUILDER DECLARATION
Signature of Applicant: Date:
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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 sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to HAZARDOUS D4A"I'ERIALS DISCLOSURE
construct the project(Sec.7044,Business&Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. I will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
declarations: Health&Safety Code,Section 25532(x)should I store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material, Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued, will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this 9 Date; /
Owner or authorized agent
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 subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked, work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I 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
upon the above mentioned property for inspection purposes.(We)agree to save ARCHITECT'S DECLARATION
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18, j
Signature Date
i
SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT• BUILDING DIVISION
10300 TORRE AVENUE•CUPERTINO, CA 95014-3255
CUPERTINO (408)777-3228 • FAX(408)777-3333 •building&cupeItno.org
-2-D
PROJECT ADDRESS APN!F 31 '5 0-1 c) B(_o . be
OWNERNANM
� PHONE
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/ - V-1 111
STREET ADDRESS "`
DDRESSr _ CITY,STATE ZIP , �j
FAX
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CONTACT NAMEp PHONE E-MAIL
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STREET ADDRESS CITY,STATE,ZIP FAX
❑ OWNER ❑ OWNER-BUILDER C3 OWNER AGENT CONTRACTOR ElCONTR4CTOR AGENT El ARCHITECT C1 ENGINEER El DEVELOPER El TENANT
CONTRACTOR NAME LICENSE NUN[BER LICENSE TYPE BUS,LIC#
COMPANY NAb[E E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP _ PHONE
ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC#
COMPANY NAME E-MAIL FAX
STREET ADDRESS CITY,STATE,ZIP PHONE
DESCRIPTION OF WORK -
4-_Kv �i
USE OF EjSFD Or Duplex ❑ Multi-Family ILLUMINATED SIGN TYPE NO.OF SIGN AREA VALUATION
STRUCTURE: inercial (Y/N) (CODE) SIGNS (SQ.FT.) (S)
SIGN TYPE CODES:
B - BANNERSIGN M - MONUIV[ENT(GROUND)SIGN
BL - BLADESIGN P - PROJECTINGSIGN
D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN ,T -TEMPORARY
E - ELECTRONIC W 1- WALL SIGN
READERBOARD WI - WMOW SIGN
EIEF€EFT� � -Y � � _ TOTAL VALUATION:
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 vith all applicable local
ordinances and state laws relating to building construct' n. I authorize representatives of Cupertino to enter the above-identified property for inspection purposes.
Signature of Applicant/Agent: Date: --" —
SUPPLEMENTAL INFORMATION REQUIRED — �� usrio _ L �
�SitePlan _Riease _ �Ra
vations nec " 'momD nx•c - -' -
_STgn Details-including UL listing(s)applicable
Structural Calculations(if applicable)
Yof Planning Approval Letter or Meeting with Planning Prior to R
submittal of Building Permit application.
SignApp_2011.doc revised 03/16/11
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Building Department
City Of Cupertino
10300 Torre Avenue
Cupertino, CA 95014-3255
Telephone: 408-777-3228
C U P E RT 1 N O Fax: 408-777-3333
CONTRACTOR SUBCONT CTOR LIST
JOB ADDRESS: - f<' PERMIT
OWNER'S NAME: PHONE# 4/eY-- 02'
GENERAL CONTRACTOR: BUSINESS LICENSE#
ADDRESS: CITY/ZIPCODE:
*Our municipal code requires all businesses working in the city to have a City of Cupertino business license.
NO BUILDING FINAL OR FINAL OCCUPANCY INSPECTION(S) WILL BE SCHEDULED UNTIL THE
GENERAL CONTRACTOR AND ALL SUBCONTRACTORS HAVE OBTAINED A CITY OF CUPERTINO
BUSINESS LICENSE.
I am not using any subcontractors:
Signature Date
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
Painting/Wallpaper
Paving
Plastering
Plumbing
Roofing
Septic Tank
Sheet Metal
Sheet Rock
Tile
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rtificate of Com fiance Sin Li btin (Page 1 of 4) SLTG-1C
ct Name:
2-
Project
Project Address:
9 6 vC/—
Location of Sign ❑Outdoor Signs ❑Indoor Signs
Phase of Sign Construction 193 New Signs ❑Sign Alterations
Type of Lighting Control ❑New Lighting Controls ❑Replaced Lighting Controls ❑Not Installing Lighting Controls
This Certificate of Compliance includes the following components(check all that apply)
❑Mandatory Measures(Lighting Controls) ❑Maximum Allowed Lighting Power ❑Specific Lighting Sources
1. Certificate of Compliance Declaration Statement(this maybe a CIO,C45 or other eligible person)
if I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and
correct.
Im eligible under Division 3 of the California Business and Professions Code to accept responsibility for the lighting design.
This Certificate of Compliance identifies the lighting features and performance specifications required for compliance with
Ti e 24,Parts 1 and 6 of the California Code of Regulations.
17 The design features represented on this Certificate of Compliance are consistent with the information provided to document
this design on the other applicable compliance forms,worksheets,calculations,plans and specifications submitted to the
enforcement agency for approval with this building permit application.
Name: Signature
� vrV� `f u C�r,�,t� _
Company: Phone
C V � R Z6 b 8 3�
Address: License number(may be contractor's He#)
�vi�' � ri✓.��Vs' � 7 s � o8
City/State/Zip: Date
2. Installation Certificate(to be signed by responsible person after installation)
Permit number ChediedbyMew
theMnN=mat Apaq Uw
Installation Declaration statement
E I certify under penalty of perjury,under the laws of the State of California,the information provided on this form is true and
correct.
I am eligible under Division 3 of the Business and Professions Code to accept responsibility for construction,or an authorized
representative of the person responsible for construction.
C I certify that the installed features,materials,components,or manufactured devices identified on this certificate conforms to all
applicable codes and regulations,and the installation is consistent with the plans and specifications approved by the
enforcement agency.
C I certify that the requirements detailed on this Certificate of Compliance have been met.
❑ I will ensure that a completed,signed copy of this Installation Certificate shall be posted,or made available with the building
permit(s)issued for the building,and made available to the enforcement agency for all applicable inspections. I understand
that a signed copy of this Installation Certificate is required to be included with the documentation the builder provides to the
building owner at occupancy.
Company Name:
Responsible Person's Name: Responsible Person's Signature: 3, �
License number(may be contractor's lie ft) Date Signed: Position With Cgmphny:z t , 3
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2008 Nonresidential Compliance Forms October 1010
Certificate of Coln Bance S' n Lighting) a e 2 of 4 SLTG-1C
Project Name: Date:
3.Mandatory Sign Lighting Controls
NOTES.
1. The same responsible person may install both the sign lighting power and the sign lighting controls, or a different responsible
person may install the sign lighting controls than the responsible person installing the sign lighting power.
2. The Mandatory Measures(sign lighting controls) are required for compliance with the sign lighting Standards.If the person
responsible for installing the sign lighting power is not also responsible for the sign lighting controls, then the owner of the
sign,general contractor,or architect shall be responsible to have the sign lighting controls installed.
3. If more than one person has responsibility for compliance, each responsible person shall prepare and sign a Certificate of
Compliance and an Installation Certificate applicable to the portion of construction for which they are responsible;
alternatively, the person with chief responsibility for construction shall prepare and sign the Certificate of Compliance
Declaration Statement or the entire construction.
3a. Statements of Responsibility:Any person signing the Certificate of Compliance Declaration Statement on page 1 of
4 on this SLTG-1 C shall complete Part 3a.Check Yes or No for all of the following statements:
1 I have responsibility for installing the sign lighting controls
❑Yes,complete parts 3a and 3b of this form ❑No,complete part 3a of this form
2 There are no existing sign lighting controls and I will be installing compliant sign lighting controls
❑Yes ❑No
3 There are no existing sign lighting controls and someone else will be responsible to install compliant sign lighting controls
❑Yes ❑No
There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and I will be
4 installing compliant sign lighting controls
❑Yes ❑No
There are existing sign lighting controls that do not comply with the applicable provision of§119 and§133 and someone else
5 will be responsible to install compliant sign lighting controls
❑Yes ❑No
3b.Mandatory Sign Lighting Controls
If the person signing the Certificate of Compliance Declaration Statement on page I of 4 of this SLTG-1C is responsible for
complying with the sign lighting control requirements,that person shall answer all of the following questions:
If there are construction documents,indicate where on the building plans the
in datory measures(silM lighting control)note block can be located:
1 §133(a)l.All indoor sign lighting is controlled with an automatic time switch control that complies with the Y N NA
a licable r uirements of§119. 1l ❑ ❑
§133(a)l and 2. All outdoor sign lighting is controlled with an automatic time switch control plus a photo Y N NA
2 control,or an outdoor astronomical time switch that comply with the applicable requirements of§119. MI ❑ ❑
Exception to§133(x)2. Outdoor signs in tunnels or large covered areas that require illumination during Y NA
daylight hours. ❑ ❑
§133(a)3. All outdoor signs are controlled with a dimmer that provides the ability to automatically reduce Y N NA
sign ower by a minimum of 65 percent during nighttime hours. 14 ❑ ❑
Exception i to§133(a)3. Signs illuminated for less than one hour per day during daylight hours. Y NA
3 ❑ ❑
Exception 2 to§133(a)3. Outdoor signs in tunnels or large covered areas that require illumination during Y NA
daylight hours. ❑ ❑
Exception 3 to§133(a)3.Only metal halide,high pressure sodium,cold cathode,or neon lamps used for Y NA
illuminating signs or parts of signs. ❑ ❑
§133(a)4. An Electronic Message Center(EMC)having a new connected lighting power load greater than Y N N/A
15 kW has a control installed capable of reducing the lighting power by a minimum of 30 percent when ❑ ❑ ❑
4 receiving a demand response signal that is sent out by the local utility.
Exception to§133(a)4.EMC required by a health or life safety statue,ordinance,or regulation,including Y NA
but not limited to exit signs and traffic signs. ❑ ❑
Field Inspector Notes: �
2008 Nonresidential Compliance Forms October 2010