120401484.—
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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10919 N WOLFE RD CONTRACTOR: 4' __ PERMIT NO: 12040148
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OWNER'S NAME: CUPERTINO VILLAGE LP j ,0, t �51< (� f t S,1DATE ISSUED: 04/26/2012
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OWNER'S PHONE: 4086685066
PHONE NO:
❑ LICENSED CONTRACTOR'S DECLARATION
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ELECT PLUMB
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BUILDING PERMIT INFO: BLDG
License Class Lic. # /�
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Contractor Date ell Z6.4 0) 2.
MECH RESIDENTIAL COMMERCIAL
I hereby affirm that 1 am licensed under the provisions of Chapter 9
JOB DESCRIPTION: JERKY KING - INSTALL ILLUMINATED CHANNEL LETTER
(commencing with Section 7000) of Division 3 of the Business & Professions
WALL SIGN AS BUSINESS STORE FRONT NAME SIGN PER
Code and that my license is in full force and effect.
PROPERTY'S SIGN PROGRAM
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
Sq. Ft Floor Area:
Valuation: $2000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
APN Number: 31605051.10919
Occupancy Type:
APPLICANT CERTIFICATION
1 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
/
Signature Date _ 26_ )�
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Issued b Date
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following two reasons:
installed without first obtaining an inspection, 1 agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
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
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(x) should I store or handle hazardous material.
permit is issued.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
1 certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Health & Safety Code, Sections 25505, 25533, and 25534.
Compensation laws of Califomia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owner r 9Fi9 agent:
Date: 2(/%
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forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
I hereby affirm that there is a construction lending agency for the performance of "ork's
correct. I agree to comply with all city and county ordinances and state laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCHITECT'S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18•
I understand my plans shall be used as public records.
Signature Date
Licensed Professional
CITY OF CUPERTINO
FEW FEE ESTIMATOR - BUILDING DIVISION
1AADDRESS:
10919 n. wolfe rd.
DATE: 04/26/2012
REVIEWED BY: bobs.
APN:
BP#:
*VALUATION: 1$2,000
*PERMIT TYPE: Building Permit
f 11['4 7 "IrT 1,1_1
PRIMARY Sign
USE:
O
PENTAMATION 1 CEAP5
PERMIT TYPE:
WORK
install illuminated store front sign.
SCOPE
Suppl. Insp. Fee -.0 Reg. C) OT
SIGN TYPE
FEE ID
QTY/FEE
QTY
SIGN FEE
IESIGN
Wall Sign, Electric
1SIGNWELEC
Elec. Pen -nit Fee: ]EPERMIT
1
O
$260
Permit Fee:
$260.00
Suppl. Insp. Fee -.0 Reg. C) OT
T—O.-07
—1irs
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Work Without Permit? C) Yes E) No
$0.00
TOTALS:
$0.00
Travel Documentation Fee: I TRA VDOC
$260.00
Strong Motion Fee: IBSEISMICO
..... .. ...f.
. . ....... . ...........
FEE
QTY/FEE
# Branch Circuits 1 $44.00
IESIGN
Suppl. PC Fee: (D Reg. 0 OT
1 0.0
Elec. Pen -nit Fee: ]EPERMIT
$0.00
O
Other Elec. Insp. L.0] $44.00
L
Permit Fee:
$260.00
NOTE: This estimate does not include fees due to other Departments (Le. Planning, Public Works, Fire, Sanitary Sewer District, School
District. eta). These fees are based on the Dreliminary information available and are only an estimate. Contact the Dent for addn 11 into.
FEE ITEMS (Fee Resolution 11-053 Fff. 71111.1)
FEE
QTY/FEE
MISC ITEMS
Suppl. PC Fee: (D Reg. 0 OT
1 0.0
1 [us
$0.00
Permit Fee:
$260.00
Suppl. Insp. Fee -.0 Reg. C) OT
T—O.-07
—1irs
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Work Without Permit? C) Yes E) No
$0.00
Sign Master Plan: 0 Yes (D No
$0.00
Travel Documentation Fee: I TRA VDOC
$44.00
Strong Motion Fee: IBSEISMICO
$0.50
Select an Administrative Item
Bldg Stds Qomffi.ission Fee: IBCBSC
$1.00
$393.50:
.. ..... . .
$0.00:
$393.50
Revised: 0410112012