03060194 CITY OF CUPERTINObv„
BUILDING DIVISION PERMIT CONTRACTOR�INFORMATION ,".,
M. .r.O. •� N:;�
BUILDING ADDRESS: SIGNTECH ELECTRICAL ADVERT 91FIND03060194
NER'SNAME: 4444 FEDERAL BLVD PewMrr ksue DA7s
E: (619) 527-6100 SANITARY N0. - CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O o LICENSED CONTRACTOR'S DECLARATION-
1 Wrcby sf0rm that I am licensed under provisions of Chapter 9(commencing lob Description
with Section 715%0 of Dlvision B of the Business out N.mtaiom Code.end my license is
s in full fore off
>,M= License Cl 5 Lk. ( 0' REVISION--IN HOUSE USE ONLY
��� Do — e Cmntam NO NEW PERMIT ISSUED, ORIG. #03060005
ARC TECTS D ATIN
IN� I as 11 be gay He r Iti
JyU r
Lice n uinnel
7 O NER-BUILDERDECLARATION
2 q 1 hereby affirm that I am exempt from the Contraamrs License Law for the
1000 following mums.(Section 7101.5,Business and Professions CMe:Any city or county
<r which requires a Permit to construct alcor,bnprovo.demolish,or repair any structure
prior m is issuance,also requires the applicant for such Permit to file ulgned statement
££ < that he is licensed pursuantmone pmvisinnsofthe Commctor'sLiccnsefaw(Chi Nor 9 Sq.Ft. Floor Area Valuation 0
Y S (commencing with Section 7")of Division 5 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjccls the applicant to a civil penalty of 3@&N0Quacr00 Occupancy Type
not more Nan five hundred della.($500).
❑1,uownerof the property, re is employees withwages r their(Sec.
c0m,Business
well Pr fesiork,and due swaumistori Licensanded e opland Law
of apply to an owner
;psfQfsft�red n$Qe�1
and property
obis Code:The Contractor's License Lew duo not apply lf an owner of 3 04 — ROUGH 8LL'��C 11�1C.HLQBS
proPeny who builds or improves Iheroon.and who dos such work himself or through his
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,the owner.
builder will have the burden of proving that he did nm Wild or improv:for puryo¢of
tale.). x//777
0 L u owner of the property,am exclusively contracting with licensed contractors tu
construct the project(Sec.70".Business and Professions Code:)The Conusemi s U. /
cents law does not apply to an owner of property who Wilds or improv thereon,and l\�
who contracts for such pmjecu withacontescmr(m)licensed pursuant m the Comeacoor's
Lkerse Law. (�r
0 lamexomptuulki Sec. ,B@PCforlMsmtaon \
rear Data
WORKER'S COMPENSATION DECLARATION `Cv\
1 hereby aBirm under pcmlty,of perjury one of the following declarations:
1 have and will maintain•CeniOran of Consent to self-Inaum forworaces Compere
scion,is provided for by Section 37W of the Labor Code.for the porformanc,of the
work for which this permit is Ismid.
0 1 have and will maintain Worker's Compensation Insurance, required by Section
57Wof the LAW,Code.for Ne performmotorthe wo h thiaparmittsitamd.
My Workers Compensation Insunrum canter and Policy nu w ram:
Carrier. �pN Polity Z/'
CERTIFICATEOF f10N FRORO M WORKERS'
COMPENSATIOSATION INSURANCE
frusxeum reed net becompkaxi ifflit pennh is foram hundred dollars(SIM)
or less)
I certify that in the performance of the work for which this Permit is issued.I shell not
employ any person in any manner an as to became subject o the Worker'Compensation
Laws of L1lif maie.Doc
Applicant
NOTICE TO APPLICANT:IL after making this Certificate of Exemption.you should
become subject to the Worker's Compensation previsions of the IaMtr Code,you must
.J O forthwi in comply with such provisions or this permll shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
'N I hereby affirm that them its construction lending agency far lad performance of
LYi the work fur whim this pmmtit Is iumd(Seers 7097.Civ.C.) ^
{I] A (antler's theme
z Lenart Add., ...
U Q 1 certify Nu I have read this application and sum that the acove information is
Is. F correct 1 agora to comply with all city and county rudinarxss and ante laws mlatin{to -
O U Wilding construction.and hereby accounts mpresenutivu of this city matter upon the
shove-menLiurcd property for inspecdon puriwes
C (We)egrec to tate,indemnify and keep harmless the City of Curanim.geinst
iF•r fn liabilities judgments,cams and expenses which may in any way accrue against said City
U z
Lo COnacqUi1nmy the granung of Nis permit
" APPLIC NDE ST DSA ILL COMPLY WITH ALL NOWPOINT Issued by: Date
U lo
Re-roofs
Si{rte a fApplic Co acmr Date
AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will ohm applicant or future Wilding uc<upant acore or handle hazardous materiel
as dented by the CanariaMuni ipat Code.Chapter 9.17,and the Result and Safety
Wc,SecYon Nution 75552(a)? All roofs shall be inspected prior to any roofing material being installed.
Will the app0u4nt or future building occmpanl use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
7dLu
hmardnus air contsmina &flood by the Bay Arca Air Quality Management all new materials for inspection.
ict?
0Yns u
lhavereadthehrrardrmsmamrhOrcquiremc uumkrChapter6.95oftheCalifor-
ealth&Satay Sections 25505.25575 SN.I undo thuif the Wilding
not c ave a n Net it ts m rsibiliry m notify ant of the
m m Merm of crdfica of a Signature of Applicant Date
7
er tar cum mcd aged V Date All roof coverings to be Class"B"or better