09040017 CITY OF CUPERTLND5'e'vkt8'
BUILDING DIVISION PERivIIT CONTR�CTOR'+INFORMATION.., -
7x A. 'a*2A+B'ta uai-'ATOR 'iik 6.r^a .a=•�`
BUILDING ADDRESS: PERMIT NO.
10381 DE ANZA BLVD CPS SIGNS
OW NEWS NAME: PERMrr ISSUE DATE
PHONE: A COMROL NO.
(510) 793-2471
ARCHITECr/E.NGINEER, BUILDING PERMIT INFO
BLDG E1ECT PLUMB MECH
areZ
0o LICENSEDCONrRACIORSDEC1ARATION Job Description
uC 1 tereby afnm m,t 1 m Ileensd umkr provision.of Ctapt«9(commenting
;zW with Sation701k1)ofDiviaon3ofNe Bud«st and Fofcaio. ade.+rW mylittncu
+M„ to Put re amenea i ' INSTALL 2 SETS CHANNEL. LETTERS, SIGNS ON BLDG
,qz LleenmOaa e,ti� LW.P `6.�S1o3
e_o Date T—z;_3 a� cammcWr � S SiLAG RE—FACE MONUMENT SIGN. CAP OFF ELECT, TO TWO
ARCHr1ELTS DFC ON
�m understood I uerundeunderstoodNW u amy plans all used public
hlic rtcMcvrds SIGN
'c G U.d PNra::ronal
t OWNER-BUILDER DECLARATION
I thereby mBm del I am.empt from dm Contractor,Licons Law for the
p o following 2•."n.(Sadao 7M I.S.Business and Profession.Cade:MY city ar emamy
K m�+ which on rhes a permit W ca.uset alter.improve,demolish.or repair any structure
z y prior W its is uened,alta requires the appliesm far such permit to rile a signed statement
< that W is licensed p«suam to the pmvisods of use contractor,Liana Law(chapmr 9 Sq. Ft. Floor Area Valuation
YFO (commencing with Section/0(0)of Division 3 of the Business and Profession Code)Or
y that he is exempt thwfmm and and basis for the alleged esemptio.Any violation of $6500
Seed..70313 by any ap,Ra m(.a Permit subjects the appliean to a m.B pcmdly of APN Number Occupancy Type
n«roam thada BKhumedd.lWa(ss001, 35917005 . 00
1,u aw«s of Ute yopcary,«mY wPlaYce with wage u the'v sole campcwtian,
will da the wart.and the suunu¢u not intended or affeam for sald(Sec.7044,Business Required Inspections
and Pwfass .aCmc:The Cmudewr,Lies •law does rot apply W ad owener of 9 P
Property wind builds orimpmves thwon,and whodocas«hwark himself ar through his
awn employee.provided dist such impmwments art oat intended or offered f«sale U.
however,the building or improvement u said within one yen of cmnpudan.the ownea-
Wilder will have the buNcn o(pmving that he did out Wild Or im marm for pursue,of
sats.).
I,as awns orust,pre'rty.am cxd.imly contracting with licensed comrsebas W
consume,the prejen(Sec.70d4.Business am Prof.A.Code:)the Coduaciarf V.
cease law doe out apply to an anter of Prupeny who Wilds or bnpm hes Meson.and,
who contracts for such project,with a cantraemr(s)licutsd pursuant W the Contractors
:'Odd,law.
I]I am..-mp,order Sc .B APC for this—a
Owner Date
WORKERS COMPENSATION DECLARATION
1 totally afrum under penalty of perjury m of the fallowing declarations:.
,1 have and will maintain a Cerdficate of Consent to self-insure for Warkers Compcn.
'On.as provided for by Section 3700 of the labor Code.for that Performance of the
wart for which this permit is laded.
❑1 lave and win maintain Workers Compensation Insuranct,u required by Sectio
3700 of cite tat«Cmc.for the pcdomanee of the work(err which Nu Permit as haled.
MY Workers Cbut pemaOnto Inserter¢carrier and Policy number>R:
Omer. Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(this section need not W camplcted if,le Pani,it;forced hundred dollars(SIOM
orV s)
I ecadF that in the performacem of the work far which this Permit Is issued,)shall not
employ any person in anyman r,,ttqq u W!acme subject to the Warkw'Campmeation
x Laws of CaliforrlP�ff��Date [neat�2^r4
NOTICE TO ct 0 ft ANr:hA fur, eking n u Coificote d(E Labor o Code.you slmuW
h6«ne Subfa�y IW W«hCroGwpCiWdon umnsiams;p,MitaA of Nemedrmake. mLLa
� Z forthwith damnlr with tern luoaido.or this pcatin that W aa,nea rewtdd.
Z O; CONSTRUCnON LENDING AGENCY
(=.N 1 hereby afrrre mat there Its c« bed,lerwing agency far the perfumance err
fY Ito wart fur which Nis Permit u issued(Sec.3097,CH.C)
m Landers Name
a. Lesdva Address
U 0 I«airy that I have req this appliea ian and ante that the thaw information is
Ll, F corrin 1 agrco to comply with All city and county ordinances and awe laws misting W
.pU building construction.and herebyauthariar noremntive ofthis city to deur upon tW
•how-mentioned P.pcny fm inspection puaposs
(9<e)agree W save,indemnify and kap harmless;ate City of Cupertino against
rd/1 liabilities.Judgments,hear aed expenses which may is say way amne agar.,said Cry �7
f
U z APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGU 0 S -
/ «. � ?
,ensnare ofevpli anW3emr �^ ante Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will tic applicant or future building ocenpantstore orhandle barallous material
as dcRrmd by Oe Calamine Municipal Code.Chapter 9.12 and dhe Health and Safety
Code.Section 155310)? All roofs shall be inspected prior to any roofing material being installed.
❑Ye
Will the applicant or future Wilding occupant es equipment Or denim which If a roof is installed without first obtaining an inspection,I agree to remove
emit barwdn.At contaminants at defined by the Bay Area Air Quality Mangwcnt all new materials for inspection.
District?
(]Y. �Na
1 have mad on,hada mus materials requirements underChmcrb.95ofWesCili(Df-
nia Health A Safety Codd,Section 15505.25533 and 25534.1 understand thadthe Wilding
dao no,currently haw a urns Nat it IS MY retpde ihilitY W nadfY tin occupant of the
requitamcrywhlch mus be pnarW utncoafa Cersrheateafareopocy. Signature of Applicant Date
1' All roof coverings to be Class'n"or better
Owner«autham d agent Date