B-2016-3301 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-3301
19600 VALLCO PKWY STE 170 CUPERTINO,CA 95014(316 20 108) ACTIVE SIGN CO
SAN JOSE,CA 95133
OWNER'S NAME: KCR DEVELOPMENT DATE ISSUED:12/20/2016
OWNER'S PHONE:408-343-1088 PRONE NO:(408)297-6640
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-11. Lic.#622021
Contractor ACTIVE SIGN CO Date 01/31/2017 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH RESIDENTIAL X COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
SUITE 170-INSTALL 1 ILLUMINATED WALL SIGN-ATLAS
I hereby affirm under penalty of perjury one of the following two declarations: HEALTH
i. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
,performance of the work for which this permit is issued.
cl I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
p- I is issued. Sq.Ft Floor Area: Valuation:$1100.00
"L • REV_ 1, I
I certify that I have read this application and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 316 20 108
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 against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City in consequence of the granting of this permit.
Additionally,the applicant understands and will comply with all non-point WITHIN 180 DAYS OF PERMIT ISSUANCE OR
source regulations - the Cupertino Municipal Code,Section 9.18. 180 DAYS FAOM LAST CALLED INSPECTION.
Signatui'e Date 12/20/2016 Issued by:Abby Ayende
Date: 12/20/2016
# iJ UILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofmg material being installed.If a roof is
1. I,as owner of the property,or my employees with wages as their sole installed without first Obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:12/20/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. I have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. Health&Safety Code,Section 25532(a)should I store or handle hazardous
I certify that in the performance of the work for which this permit is issued,I
material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERIIFICATION Date: 12/20/2016
I certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
I
correct.I agree to comply with all city and county ordinances and state laws hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
's
to enter upon the above mentioned property for inspection purposes. (We)agree LenderName
to save indemnify and keep harmless the City of Cupertino against liabilities,
'
judgments,costs,and expenses which may accrue against said City in Lenders Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARATION
'
Code,Section 9.18. I understand my plansshall be used as public records.
Licensed
Signature Date 12/20/2016 Professional
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SIGN PERMIT APPLICATION
COMMUNITY DEVELOPMENT DEPARTMENT•BUILDING DIVISION
51.4, 10300 TORRE AVENUE• CUPERTINO, CA 95014-3255
44,
(408)777-3228• FAX(408)777-3333•buildinq(a,cupertino.orql
CUPERTINO
PROJECT ADDRESSI'i(
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CONTACT NAME 714PHONE 4"ors (p Kg.. tidievot-1E13 E-MAIL eI
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El OWNER 0 OWNER-BUILDER 0 OWNER AGENT ID CONTRACTOR Eir CONTRACTOR AGENT 0 ARCHITECT 0 ENGINEER 0 DEVELOPER 0 TENANT
CON-TRACTOR NAME LICENSE NUMBER LICENSE TYPE
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STREET ADDRESS__ CITY,STATE,ZIP
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ARCHITECT/ENGINEER NAME LICENSE NUMBER BUS.LIC E
COMPANY NAME E-MAIL FAX
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DESCRIPTION OF WORK pi 5TfaithAritot4 U)
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USE OF SFD or Duplex Ej Multi-Family ILLUMINATED SIGN TYPE NO.OF SIGN AREA VALUATION
STRUCTURE: g Commercial (Y/N) (CODE) Sign (SQ.FT.) ($)- -
SIGN TYPE CODES; 41. L 42A. 'lost
B - BANNER SIGN M - MONUMENT(GROUND)SIGN
BL - BLADE SIGN P - PROJECTING SIGN
D - DEVELOPMENT ID SIGN SP - SPECIAL EVENT BANNER
DI - DIRECTIONAL SIGN T - TEMPORARY
E -- ELECTRONIC W - WALL SIGN
READERBOARD WI - WINDOW SIGN
RECEIVED BY: a*Cui TOTitriAdoTION:
By my signature below,I certify to each of the following: I.m the property owner or authorized agent to ac on the property owner's behalf. I have read this
application and the information I ded is correct. .ve read the Description of Work and verify it is acCurate. I agree to comply with all applicable local
ordinances and state laws relaf.g.to bui.oing constructio, Ta . in representatives of Cupertino to enter the a ove-identified property for inspection purposes.
Signature of Applicant/Agent: , Date:7-, C
SUPPLEMENTAL INFORMATION REQUIRED OFFICE USE ONLY
Site Plan PLAN CILECK TYPE ROUTING SLIP
Elevations 0 OVER-THE-COUNTER 0 BUILDING PLAN REVIEW
Sign Details-including UL listing(s)applicable 0 EXPRESS
0 PLANNING PLAN REVIEW
Structural Calculations(if applicable) 0 STANDARD 0 OTHER:
Copy of Planning Approval Letter or Meeting with Planning prior to 0 LARGE
submittal of Building Permit application.
D MAJOR
SignApp_2011.doc revised 03/31/11