03090139 r
C I'CY 011 CUI'HRTINO =' s �' -- 77.
BUILDING DIVISION PERMIT CON TRACTORANFORMATIOLN-
BUILDING ADDRESS: PERMIT NO03090139 3090139
OWNER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECII
0 0 0
100 LICENSED CONTRACTOR'S DECLARATION
LFF 1 hereby affirm that 1 am reelectedunder provisions of Chapter 9(commencing Job Description
e2ty with nion]II(g1l of Division Jof the Business and Profcssinns Codc,mdmylimnsis
,`a mml�and erne _ J 1p `7 SIGN �� ��
Lice s alt
-rc Dam D CONTRACTOR: THE CANVAS AW N
j mamidARCHITECTSD .ARA3
I d ED
1 undcrslanJ my phos shall k as puhlic reavJs
JaU
0G LiecnmdProfessional OCT #32003
OWNER-BUILDER DECLARATION
vi
a I 1 hereby affirm that I am exempt from the Contractor's License Law for the
00 following reason.(Section 7031.5.Business and Professions Code:Any city or county
<m which Mortimer a Permit to construct.alter,improve,demolish,or repair any structure
prior it)its issuance.also requics the applicant ror.such permit to Glc a.signed statement
zip that hcls licenced pufsuam ,,the prnv,ai,,.ofthe Carl...lots Liecnsc Law(Chapter 9 Sq. Ft. Floor Area U 0
2t: (commencing with Section 7")of Division 3 of the B usiness and Professions Cose)or
thn he is exempt thearrom and Use bssis for the alleged exemption.Any violation of rrAA,,gqww��AH,
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of 3 TDa1s( Nti7®e7 0 0 - OCCType
not more than five hundred dollars($50(l). - - --- U pane Y - ----
❑I,m owner of she property.or my employee with wages ax then sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec 70&1,Buri toss
and Professions Code:The Contractor's License Law does not apply m an owner of Required Inspections
property who builds or improves demon,and who does such work himselfor through his - 304 — ROUGH ELECTRIUAL
own employees,provided that such improvements are not Intended or offered for sale.If, 505 — FINAL ELECTRICAL
however,the building or improvement is sold within one year of completion,thc owner. _
builder will have me burden of proving Nal he did not build or improve for puryost,of
asm).
1,as owner of but property,am exclusively contracting with licensed convectors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such plccts with a contractor(s)licensed pursuant o tk Contractor's
Limn law.
❑ 1 am exempt under Sec. B&P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following decimation:
❑1 Kan and will maintain a CeniOcam of Consent to self-insure for Woraer'sCumpen-
cation,as provided for by Section 3700 of the labor Cede,for the arformnnm of the
work for which Nis permit is issued.
❑I have and will maintain Worker's Compensation Insurance.as required by Section
37W of the labor Code ror the performance or Ne work for which this permit is issued.
My Worker's CmIo,a`em-.Aii``yyn Insurance Caro rand Policy number am: �AI
Ca 'e'. YM1�sw+W.) bl �-hey No.: -WUli42Q
CERTIFICTE OF % MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut becompleted ifft permit is fmooe hundred dollars($100)
in,Ices.)
1 certify Nat in the performance of the work for which this permit is issued,I shall not
employ any person in any manner m a bt become subject n the Workers Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this Cenifmle of Exemption,you she.Id
become subject to the Worker's Compo nsmion provisions or the labor CMc,you most
z forthwith comply with such pmvisiom or this permit shall k deemed revoked.
Z'O CONSTRUCTION LENDING AGENCY
1 hereby affirm Nat there Is a conslmction lending agency lot the performanm of
Y Ne work for which this permit is issued(Sec.301 Civ.C.)
Y] Lender's Name
3.
Z lender's Address
Z)O 1 certify ton 1 have read this application arta sum mal the above information is
1. Pcorrect.1 agree to comply with all city and county ordinances and scam laws mating to
U building consuuctlon,and hereby anhorim representatives of this city to enter upon the
ahovn(W tia agree
property for inspection an keep ee.
W
(We)agree to sant,indemnify and Wap M1ay in an the City of against against
Z in Consequence
or the costsang cxyonesmit. may in any way seems against said City
;� z in eonmyuenec ofthe graining of this permit.
^� APPLICANT UN ERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU NS.
Iv v Re-roofs
gnatvrc of Apprcan✓Comracmr I Doc
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occ.,a.t stere m handle hoarchis material
of defined by the Cupertino Municipal Code.Chapter 9.12,and the Health and Safety
Code.Scamn 25572(.)? o All roofs shall be inspected prior to any roofing material being installed.
❑
Ya
Will the applicant r fumm budding occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hvardous air Contaminants as Jcfined by the Bay Arca Air Quality Management all new materials for inspection.
Diau,mt]
❑Yes RNu
I love mad the hand nus materials requlremenu under Chapter 6.95 of the Califnr
nia Hcabh&Sarcty Codc.Section 25N15.25533 and 25534.1 unJ mind thm if the Wilding
Jon,not cmrcn0 hoc a tenant Na it is my responihility m fy the mcupant of Nc
regi entsw elk p ntismmcennCeroreate ere ey. Signature ofApplicant Dale
All roof coverings to be Class "B" or better
Owner or authorised agent bibe
CITY OF CUPERTINO
Item 1 of 1 PERMIT RECEIPT OPERATOR: conniew
COPY # 3
Sec : Twp : Rng : Sub : Blk: Lot :
APN . . . . . . . . : 35910060 . 00
DATE ISSUED. . . . . . . : 09/18/2003
RECEIPT # . . . . . . . . . : 23190
REFERENCE ID # . . . : 03090139
SITE ADDRESS . . . . . : 10215 DE ANZA BLVD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . .
OWNER . . . . . . . . . . . . : VARDY-MIKE LLC
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : ,
RECEIVED FROM . . . . : ALL SIGNS SERVICES
CONTRACTOR . . . . . . . : LIC #
COMPANY . . . . . . . . . . :
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . . ,
TELEPHONE . . . . . . . . :
FEE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW SAL
---- --- - -- - - - - - -- - - - - - - - - - - - - - - - --- - - - - - -
BPERMFEE VALUATION 4 , 900 . 00 107 . 00 0 . 00 107 . 00 0 . 00
BPLANCHK PERMIT FEE 107 . 00 90 . 95 0 . 00 90 . 95 0 . 00
BENERGY PERMIT FEE 107 . 00 32 . 10 0 . 00 32 . 10 0 . 00
BREMSIGNAD NO. CIRCUITS 1 . 00 4 . 44 0 . 00 4 . 44 0 . 00
EPERMITFEE FLAT RATE 1 . 00 35 . 52 0 . 00 35 . 52 0 . 00
BREMSIGNS NO SIGNS/MARQ 1 . 00 22 . 20 0 . 00 22 . 20 0 . 00
$SEISMICRE VALUATION 4 , 900 . 00 0 . 50 0 . 00 0 . 50 0 . 00
BUSLIC FLAT RATE 1 . 00 100 . 00 0 . 00 100 . 00 0 . 00
------ - - - - ---------- -- - -- - - - - - --------- -
TOTAL PERMIT 392 . 71 0 . 00 392 . 71 0 . 00
METHOD OF PAYMENT AMOUNT NUMBER
- - - ----- - - - - - - - - - - - - -- - - ---
CHECK 392 . 71 6899
TOTAL RECEIPT 392 . 71
VOICE ID DESCRIPTION VOICE ID DESCRIPTION
304 ROUGH ELECTRICAL 505 FINAL ELECTRICAL
0
CITY OF CUPERTINO U 3 v o (3
SIGN
CUPERTINO PERMIT APPLICATION FORM
APN# Date: 03
Building Address: � 'Q�J2i5lsb ,! e 470, 6bvA C ho� CA
Owner's Name: [-LL Phone#: ,yam O
Contracto r C aV QNS AWhI Cp ,��c • License#:
Contact: Phone#:
M-G44�
Applicant/Contractor:
ildi Permit Info:
Old lect Plumb Mech
lobA)escription:
Residential: q iuQ4acowz��
Commercial: ; iumiHet�.WNik
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
4qo�
Type of Construction: Occupancy Group:
Qty. if
Applialp Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees' BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmd] Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG
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UPERTINO CALIFORNIAIb.0 Yris..wmr r q y�Tr _I_f !—