04020165 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT SCOLT.
C=Tt1R YNFf?TtMA'TTQN
BQILDING ADDRESS: NORTHWEST SIGNS PERMIT NO 04020165
ER'S NAME: PERMrf LSSUEDATS
T-MOB
ONE: SANITARYNO. CONTROL NO.
(831) 469-8208
ARCHITECTIENGINEER
31 46 -
ARCHITECTIENGINEER: - BUILDING PERM"INFO
BLDG 0 PLUM MECH O
o LICENSED CONTRACTOR'S DECLARATION
ly I bemby affirm Thal 1 am licensed under provWoes of Chapter 9(commencing Job Description
x with Suction 70(10).(Division 3af the Busheesand ProfeWom Code.and my license la
�< inr.Br. e�dcrcem (�t$� SIGN--T-MOBILE
iZ License,Chea Lk.t
3 Dam Contractor—
ARCHITECTS
Ae shall E(-TS DECLARATION
1 uademand my plana shall he tteetl as public msnrda
yva Licensed Professional
OWNER-BUILDER DECLARATION
<I 1 herchy airbus that I am exempt from the Connaemr's License Law for the
po following moon.(Section 7101.5,Business and procreation Code:My city or county
u$� which requites s permit m cmlamoct.Aller.Improve,demolish,or repair any structure
P, prior m its Issuance,alto requires the applicant for such Permit la rile aa]Sued statement
^� < that he is licensed pursuant to the provisions of the Contractors License Law(Chapter 9 Sq.Ft.Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
that he is exempt therefrom and the basis for the alleged exemption.Any violation or
Section 7031.5 by any Applicant for a permit subjects the applicant At a civil penalty of 3.�HT'NI185e70 0 Occupancy Type
not mart than five hundred dollar($5007.
01,uc=ater of the property,or my employer with wages u their sure compenoationon t1
will do the work and the awmu a float banned orarfemd(or ask(Sm.7044;Business
Intl Predications Code:The Centromere License Law does nut apply m an'.or 7. � Required Inspections
properly who studios IN lmproms thmean,And whadoee,ochwmh hllnaeIrwthmY{h his
own employ=,provided Natsueh Improvements time.,intended oreffcredfuessOff. � �-
however,thelmidinSorimpuvemmliawld withinorc year area adon O.,-
builder will have tin burden of proving that he did not build or improv f tpese of
tile.).
0 1,a owner or the property.am exclusively contracting with licensed commonness;to
construct tite pmlem(Sec.70th.Business and Profeulons Code:)no contractors LI- 1 )
cense Law docs not apply An an owner of property who builds or Improves thereon,and,
who contracts for such projects with aconuacmr(s)licensed pursuant in the Contractor's
License Law.
0 l am exempt under See .B&P C for this mason
r Dau
WORKER'S COMPENSATION DECLARATION
I hereby of irm under penally of perjury one of the following demamtians:
I have and will maintain a Certificate orcomenl to eelRWwe for Workcr'a Compen.
Minn.u provided for by Section 3700 of the Leb car Code,for the performance of the
.,it for which this permit is issued.
0 1 haw and will maintain Wmaer's Compartment Insurance,u required by Semon
3700 of ft Labor Code,for Ne performance of the work for which this permit is issued.
My Worker's Com cation Insure nrtim antl Policy n�u�mbger art:
Carrier. Policy No.:�5�1 S�2
CC RTIne�PT10N FROM WORKERS'
COMPENSATION INSURANCE
(rds section need nothecompleted Inhe pmmh is fmane hundred errata(SIM)
or leu.)
1"rufY that In this performance of the wart for which this permit is homed.I shall not
employ any person in any meaner an as In became subject to the Workeri Compensation
Lamar California.Data
Applicant
NOTICE TO APPLICANT:IL after making this CertlOcate of Eacreption,you should
became subject m the Worker's CompemAtion provisions of the Labor Cade,you most
.,0 forthwith comply with each provisions or this Permit chap he deemed revpkeA.
Z.i► CONSTRUCTION LENDING AGENCY
�-+ I hereby affirm that Nem is a comtroction lendinSapency for the performatm or
Ne work for which Ibis permit is issued(Sec.3097.Civ.C.)
W�Q Lender's Name
z Lender's Address
U 1 certify that I haw read this application and sum that the some information is
Iz. correct.l&pee to comply with all city and county ordimumm and Aum laws misting to
OU buildingconswction,atW hereby mahorim representatives of this city to enter upon the
tLl show-amotioned P.Peny fm Inspection Purposes.
gy, (We)agate ro caw,indemnify and loop hamtkss the City of Cupertino against
rn liabilities.judgments.coats and expenses which may in any my ammo Against wid City
U in consequence of its,putting of this Permit.
r.. APPLICANT UNDERSTANDS A D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURC REGU TION
`y' ✓f ?_L6�-! Re-roofs
1 Sigama Cenuacur DAte
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will that applicant or future Wilding occupant store or handle ha ardou material
AmdennAd by the Cupertino Municipal Code.Chapter 9.10,and the Health and Safety
soman zss3z(a77
0Yes ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or mwre building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It haasNnu air...uminants ss defined by the Bay Amo Air Quality MmRemem all new materials for inspection.
District?
OYea 0 N
thaw
read the husNws materials requiroments under Chapter 6.95 of the Califor-
niaHrslth&SsfetyCado.Savons75505.2T5J7 uW 25531.1 underetmb Oullf Ole Wilding
d=rpt currently how a tenant.that it is my responsibility m notify the occomm or the
rctio41. nu khat be met ' issuatee ofa Cmiricam fOccas ey. Signature of Applicant Date
o ct eriyedagent �� Dam All roof coverings to be Class"B"or better