12020046CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19052 STEVENS CREEK BLVD CONTRACTOR. ii RNHT NO: 12020046
OWNER'S NAME: UNITED POLARIS INC 6 DATE ISSUED: 02/09/2012
O VNER'S PHONE: 4089058798 , PHONE NO:
® LICENSED CONTRACTOR'S DECLARATION
License Class (L-- Lie.#
Contractor � , L Date J1- ( "
I hereby atY'irrn that I aui icensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in fill force and effect
PERMITBUILDING ! S', r
ELECT j _:., PLUMB F.
RESIDENTIALMECH
JOB DESCRIPTION: MA MA CHAN'S KITCHEN - INSTALL ILLUMINATED
CHANNEL
LETTER STORE FRONT SIGN
I hereby affirm tinder 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. Sq. Ft Floor Area:
APPLICANT CERTIFICATION
I 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 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 applimt understands and will co€uply
with all non -point •ouice regulations per the Cupertino Municipal Code, Section
9.18.
Signature" = Date `? trl 79 1
® OjVNER-BUILDER DECLARATION
I herehy 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)
Las owner of the property, am exclusively contracting with licensed contractors to
construct the project (See.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 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 die work for which this permit is issued, I shall
€rot 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 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. I agree to comply with all city and county ordinances and state Iaws 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.
Valuation: $2500
APN Number: 37507046.19052 i Occupancy Type:
Issued by;-; — Date: G -
RE -ROOFS:
Alt 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
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS NiATERIALS DISCLOSURE
I have read the hazardous materials requirements cinder Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will malntaiu
compliance with the 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 Air duality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 912 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
Owner oized_agent:
Date:G!
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of iwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECT'S DECLARATION
Date
I understand my plans shall be used as public records.
Licensed Professional
CITY OF CUPERTINO
IN I
BUILDING DIVISION
FEE ESTIMATOR
ADD REV
SS: 19052 stvns crk blvd. DATE: 02/0912012 IEWED BY: bobs.
-7— 4 F$2,500
0 0 BP#: J NALUATION:
APN:
':PERMIT TYPE: Building Permit
PRIMARY PENTAMATION I CEAP5
USE: Sign PER IT TYPE:
womc, install illuminated channel letter stor front sign
SCOPE
NOTE: This estinuite does not include fees due to other Departments (i.e. -planning, i-tione worics, r ire, winifuty oewer Lnurwl, auffuut
District, etc.). These fees (ire based on the ct flie J)e I or aaan't in o.
FEE ITEMS (Fee Resohaion 11-053 fff. Z/1//11)
FEE
QTY/FEE
MISC ITEMS
S ppl, PC Fee; Reg, OLEfl
hrs,
$0.00
Permit Fee:
$260.00
Suppl. Insp. Fee-.0 Reg. 0 OT
0.0 hrS
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Work Without Permit? 0 Yes (j) No
$0.00
Sign Master Plan: 0 Yes 0 No
$0.00
Travel Documentation Fee: I TRA H)OC
$44.00
Sirol', 1'�,,fotlofl �f-ge-, IBSEISAKCO
2L
$0.53
Select an Administrative Item
Stds Conimission Fee:
B ldfy IBCBSC
$1.00
SUBTOTALS:
$393.53
$0.00
TOTAL FEE.
f $ 3 9 3. 5, 3
Revised: 1/19/2012