03020014CITY OF CUPER'I'INO
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BUILDING DIVISION PERMIT
fiyCONTRACTOR INFORMATION
BUILDINGADDRESS:
HENRY'S DESIGN & SIGN CO
PERMIT NO.
iiiiiiw 10675 DE ANZA BLVD
'R'S NAME:
�. S S O ALMADEN RD
APPLICATION SUB DATE
CANNON PAINO
02/06/2003
PONE
(408) 269-0888
SANITARY NO. CONTROL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECfI
CJ I�
LICENSED tNSEDCONTRACTOR'SOECLARATION
Job Description
ander pmv s of,Captor 9 (commencing
I hereby affirm that 1 um I me
p
wish clian7lRlo)n1:15n Bu
isinnJof the Business and Professions Code, and my license is
in to sefrrec arta
ones G— G a—Lie. w C f� >!,e/9.
SIGN (LIGHT)
Ir}r. �II B
I ale Contractor •� .G
ARCIUTECFg DECLARATION e
l understand my plans shall he used in public words
JUL 2� �3
Licensed Pmlessi ium
OWNER -BUILDER DECLARATION
N
1 hereby affirm at 1 am exempt from the Contractor's License law for the
rcaenn. (Section 7031.5, Business and Professions Code: Any city nr county
BUILDING
which requires a permit ha construct. aper, improve, demolish, or repair any structure
prior to it%issuance, also requires the applicant for such permit to file a signed summent
that he is licensed pursuant to the provisions ofthe Contractor's Licens, Law (Chapter 9
Sq. Ft. Floor Area
3a,
1ayl(9tion
(commencing with Section 7000) of Division 3 of the Business and Prol'esalnns Cndc) or
Nat he is exempt therefrom and the basis for the alleged exemption, Any violation of
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
Br
Occupancy Type
not more Nan Ove hundred dollars ($500).
❑ L u owner of Be proPeny, or my employees with wages u their sole compensation,
will do the work, and Ne structure is not intended or offered for sale (St .704, Business
—Rot
and Professions Code: The Contractor's License Use does not apply to an owner of
505 - F I NALODS
Fortuity who builds or improves thereon, and who does such work himself nr through his
son employees, pmvidc0 that such improvements are not intended or offered for sale. If,
however. the building or improvement is sold within one year of completion, Ne owner.
builder will have the burden of proving that he did not build rr improve for purpose of
sale.).
❑ 1, as Owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Contractor's Li-
cense Law does not apply so an owner of property who builds or improves thereon, and
who contracts for such projeeu with a contractor(s) licensed Pursuant to the Contractor's
License Law.
1 am exempt under Sec. B its P C for this moon
Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penally of perjury one of Ne following declurations:
I have and will mainnin a Certificate of Consent a self-insrre for WrrkersCompen-
.non, as provided for by Section 3710 of the Labor Code, for the Performance of the
work far which Nis permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, az required by Section
3700 of me Labor Cade, for the Performance of Ne work for which this Permit is issued.
My Worker's Compensation Imumm o carrier and Policy number are:
Cartier: Policy No.:
CERTIFICATE OF EXEM PITON FROM WORKERS'
• COMPENSATION INSURANCE
(7Tis section ancient becompleled ifthe Permit is forone hundred dollars(SRR)
,it las.)
I cenify that in the Perforoonce of the work for which this Permit is issued, 1 shall mol
. employ any person in any manner sit as to become subject o the Workers'Compensation
Laws of Cnlild!!!Nlmc
Applicant --�
NOTICE TO APPLIC r -I a�making this Certificate or Exemption, you should
1%emme suhjcct to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall M deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a conswction lending agency for the Performance of
the work lin which this Permit Is issued (Sec. 3107, Co, C.)
Under's Name
lender's Address
1 cenify Nat 1 have read this application and sum that the move infatuation is
correct. I agree to comply with all city and county ordinances and state laws relating to
building construction, and hereby authorira 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 agai not
liabilities. judgments, cons and expenses which may in any way creme against said City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIM'
Issued by: Date
SOU EREGULATIONS.
��. /
Re -roofs
Type of Roof
rgnamre man mntir Date—O
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hazardous material
efined by the Cupertino Municipal Code, Chapter 9.12, and the llcalth and Safety
e, Section 25532(l)?
❑Yes ON.
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, 1 agree to remove
Will theapplicant(irfuturebuildingoce,upantu.seequipmentordeviceswhich
coil hamNous it cnnWminants as dclined by the Bay Arca Air Quality Management
all new materials for inspection.
District?
❑Yes 0 N
1 have read the boolims materials requirements under Chapter 6,95 of the Califm-
nis Health ✓E Safety Calc. Sections 25505,35533 and 25534.1 undcrsund Nat if he building
does not currently have a tenant, that it is my responsibility to notify be needful of the
reyulmmentawhlchousthemet 'rat '.aces c a enill.morOceupsnny.
Signature of Applicant Date
All roof coverings to be Class "B" or better
ownorm
aWhorived agent Date