12010155CITE' OF CUPERTINO BUILDING PERMIT I
BUILDING ADDRESS: 19620 STEVENS CREEK BLVD
OWNER'S NAME: EVERSHINE V1, LP
OWNER'S PHONE: 4083431088
N LICENSED CONTRACTOR'S DECLARATION
License Class G-C/ S Lie. # 91;1 % 31 5
Contractor �G��-<-� UG��IILe.z ez� S ' Date � �� �-
I hereby affirm that I arty 1€eensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is €u fall 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.
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.
APPLICANT CERTIFICATION
€ certify that I have read this application and state that the above information is
correct. I agree to comply with all cityand county ordinances and state laws relating
to building construction, and thereby 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 -paint source regulations per the Cupertino Municipal Code, Section
9.18. Signature Jv € Gi « U I/ 6,UA t t t /�� _ Date
11 OVt'NER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
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,
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:
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 €naintai n 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 die work for which this permit is issued, I shall
not ennploy 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 the Worker's Compensation provisions of the Labor Code, I must
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. 1 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
9.18.
CONTRACTOT_. _ ) PERMIT NO: 12010155
(� LJ DATE ISSUED: 01/25/2012
PHONE NO:
9
RESIDENTIAL'
JOII DESCRIPTION: STE 200 - PNC MORTGAGE - FIVE(5)NEW SIGNS - (3)
ILLUMINATED AND ONE(I)DOUBLE REFACE
Sq. Ft Floor Area: I Valuation: $t855
APN Number: 36906012.00 1 Occupancy Type:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material be€hg 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 MATERIALS 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
connpliance with tl€e 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 all -
con tamina tits as defined by the Bay Area A€r• Quality tUanagement District I will
maintains compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Oh a o€ arrtl€o€ �zJeVCd agent:
�� �
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction tending agency for (lie performance of hiork'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.
Signature Date
Licensed
FEE ESTIMATOR - BUILDING DIVISION
1 ---7ZKA
DATE: 01/25
DATE: 011 5/2012 REVIEWED BY: GS
ADDRESS: 19620 Stevens Creek
APN: 0(0 BP#: *VALUATION:
,PERMIT TYPE: Building Permit
PE NTAMATION
PRIMARY Sign PERMIT TYPE: I CEAP5
USE:
NOTE: This, estinuttedoes not inctuaejeesaneto ornervepartriwita ii— i 7ure--6,
- — 414., n—f fAr elddl) V b2fa
District, etc.). These tees are Dflse(l Oil lite vre"RflllT •
FEE ITEMS (1,'ee 11�1e,qo/jjtjoje �L]-_O-
FEE
=F
QTIY.'/FEEF
MISC ITEMS
A
Suppl. PC Fee; (2) Reg. C' D, ��hrs
$0.00
Permit Fee:
$780.00
Suppl. Insp. Fee-0 Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$44.00
PME Pertnit Fee:
$44.00
Work Without Permit? OYes No
$0.00
Sign Master Plan: 0 Yes 0 No
$0.00
Travel Documentation Fee: ITRATIDOC
$44.00
,AIL0111(� IBSEISWCO
Q
$0.50
Select an Administrative Item
IlIdgStcls Qomtnissi�0111`f-L IBCBSC
$1.00
SUBTOTALS:
$913.50[E
$0.00 TOTAL FEE:
$913.50