B-2018-0539 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0539
6191 BOLLINGER RD CUPERTINO,CA 95014-4630(375 41 007) TK CONSTRUCTION&
ACTIVE SIGN INC
SAN JOSE,CA 95133
OWNER'SNAME:WEST VALLEY PRESBYTERIAN CHURCH DATE ISSUED:04/02/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C45 Lie.#822021
Contractor TK CONSTRUCTION&ACTIVE SIGN INC Dale 0313112019 X BLDG_ELECT_PLUMB
hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH_RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and dint my
license is in full force and effect. JOB DESCRIPTION:
WEST VALLEY PRESBYTERIAN CHURCH-NEW MONUMENT SIGN
1 hereby affirm under penalty of perjury one of the following two declarations:
r. 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,
Section 3700 of[lie Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$6000.00
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 APN Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 37541 007
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 PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupe to Municipal Code,Section 9.18, ]80 DAYS FROM LAST CALLED INSPECTION.
Signature - Date 04-02-2018 Issued by:Kim Dunbar
Date:04/02/2018
OWNER-BUILDER DECLARATION
I hereby aflirm that I an,exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining at,inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for impeolon.
sale(Sec.7044,Business&Professions Cade)
z, f,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(See.7044,Business&Professions Code). Date:04-02-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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
put formance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work far which this California Heattlr&Safety Code,Sections 25505,25533,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(.)should I stare or handle h...rdous
shall not employ any person in any m as to become subject to the material.Additionally,should f use equipment or devices which emit hazardous
manner o air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code, .25534Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:04-02-2018
1 certify that I have read this application and state that the above information Is CONSTRUCTION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm thatthereis a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec,3097,Civ C.)
to enter upon the above mentioned property for Inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City In Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Data 04-02-2018 Professional