12010114CITE' OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19375 STEVENS CREEK BLVD CONTRACTOR: GOLDEN GATE SIGN CO PERMIT NO: 12010114
OWNER'S NAME: CUPERTINO INVESTMENT PARTS LLC 711 INDEPENDENT RD DATE ISSUED: 01/17/2012
OWNEWS PHONE: 4089212814 OAKLAND, CA 9462I PHONE NO: (5I0)366-3838
® LICENSED CONTRACTOR'S DECLARATION
License Class Lic.�# j
Contractor �' t fZA(®' Date
I hereby affirin that I am licensed under the provisi us of hapter 9
(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 nvo 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
Section 3700 of the Labor Code, for the performance of die work for which this
Permit is issued.
APPLICANT CERTIFICATION
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
indemnify 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 will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.13.
e:. 11, f..
I hereby affirm that I am exempt front the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and (lie 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
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
€ 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.
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
become subject to (lie Worker's Compensation provisions of the Labor Code, I ma
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 thus city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said Ciq, in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulatiiars per (lie Cupertino Municipal Code, Section
9.18.
BUILDING PERMIT INFO: BLDG ELECT PLUMB 1„
RESIDENTIAL
JOB DESCRIPTION: CORT FURNITURE & KIDDIE ACADEMY - INSTALL NEW
ILLUMINATED MONUMENT SIGN
Sq. Ft Floor Area:
Valuation: $2000
APN Number: 31621031.19875 [ Occupancy Type:
Issued byc Date�',Z /
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 materials for
inspection.
Signature of Applicant:
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS NIATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with (lie Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Ali- Quality Management District I will
maintain compliance with (lie Cirperthno Munhehpal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
,t.._ 2 F� Poe-
rr
I here affirrn that (here is a construction lending agency for the performance of «ork's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date.
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�IYOFCUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
N -A
S VS
--FDATE:
ADDRESS: 19875 stuns crk blvd.
01/17/2012
REVIEWED BY: bob &
L,' Ef M�
APN
# -7)
"VALUATION: 1$2,000
-PERMIT TYPE: Building Permit
PRIMARY Si
Sign
PENTAMATION I CEAP5
USE:
PE: A
WORD
install new illuminated monument sign.
SCOPE I
# Branch Circuits 1 $44.00
F'ESIGN Elec.Permit Fee: ]EPERIff
Other Etec. Insp. [_0.0 $44.00
ET
NOTE: This esditutte does not include fees due to other Departntems (i.e. Planning, Public fVorks, Fire, Saultaty Sewer District, School
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FEE ITEMS (F, cc Pesohetion
FEE
QTY/FEE
MISC ITEMS
Suppl. PC Fee: 0 Reg. O'OT
Efl
tirs.
$0.00
Permit Fee:
$327.00
Suppt. Insp. Fee: Reg. 0 OTFo
-.61
firs
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Ej
Work Without Permit? 0 Yes 0 No
$0.00
Sign Master Plan: 0 Yes G No
$0.00
A
Travel Documentation Fee: I TU TIDOC
$44.00
Strongj�,/fgficg IBSEISAIICO
$0.50
Select an Administrative Item
B1 "[-.'tds Conimission Fee: IBCBSC
$1.00
SUBTOTAILS:
$460.50
$0.00
TOTAL FEE
.50
Revised: 1/01/2012