03060005 CITY OF CUPERTINO
BUILDING DIVISION PERMIT O
� ON'sLYtA.C'TUR I�NF' MA'TI
.:wMWIlft �57A
BUILDING ADDRESS: PERMIT N90 3 0 6 0 0 0 5
ER'S NAME: - PBRMIT V O y v 2/2 0 0 3
AUTO INSURANCE I / v
NE: SANITARY NO. CONTROL NO.
ARCHIIRCTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
l� L I�
1066 LICENSED CONTRACTOR'S DECLARATION JobDescription
I hereby affirm mat 1 sm Rosemead under vinau of Chapter 9(commencing
NthSecdan7 )efDivWon3ofthe Budneat Pro(esaiou Code,and mylicenseu
m
I. arc SIGN
11 Lk,N
go:mn conte CONTRACTOR: SIGNTECH ELECTRICAL ADVERTISING, IN
S9 ARCall be
n ATION �'� ` S �®
u ersund my plans MVI be used u public mcnrtls .�51►■F
=ted Licensed Pmficnional J�
OWNER-BUILDER DECLARATION OCT 4-".2003
E 1 therebyaRrm that 1 em esempl form de Conuaerors License Law for the
D O fallowing wan.(Section 7051.5.Business and Professions Code:My city or county
$ which requires a permit to emromct,slur,hnprow,dem ilm.or repair any uruuum
_zC prior ut its issuerKe,also requires Inc applicant for such permit m file a signeAatatement
that he is licensed pursuant to the provisions of the Com lows Lee.Law(Chspun9 Sq. Ft. Floor Area n
(onmmencing with Section 7000).f Division 3.f the Bedroom and Promminoo Code)or $8600
that ha k,anmpl 0urefrom and the book,for the alleged areempdon.Any violation of
Section 70513 by any applicant for a permit subjecu the applicant to a civil penally of APN Number Occupancy Type
not mart than fiw hundred dollar(5500).
❑I,uoweer of the prop.ly,.my eroployc.wine wagesoode4anle compenmdan, 36610132 . 00
will do the work.and thestucture k,not intended arefremd fmsam(Sec.704/,Bodin dins actions
and Profead000 Code:Tha Conua.ors License Law dors.1 apply m an own.of 101 - FOUNDA�� P
property who builds or improve,Iheman.and wbodoessmh work himaelfor through his
ownernployees,provided that such impronmenuam not muwed morteree resale.If, 103 — UFER
noway,Ne building sur improvenunt is sold within mon you of cmnpledm,the owrter-
Wildur MR have dm homeless of proving that be did not build.Improve for purpose of 104 — REBAR
Y4) 105 ANCHOR BOLTS
❑1.as owner of site property,am eaclulvely contracting wish licensed eonbecmn as 304 - ROUGH ELECTRICAL
construct the project(See.7014.Business and Pmfesdam Cade)The Conouur's I.I.
cow law does not apply m an Owner of property who bull"or improm merean,and, 505 — FINAL ELECTRICAL
who contracts for such lameeu with a conuactar(O licensed pursuant an Ne Commencer
License Law, 514 - FINAL PUBLIC WORKS
❑I am eaempt tend.See. ,B B PC for this won
I Dau
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury One of six following declarations: -
llow and will mdnWn s CeNOae of Consent m mlf-iooure Ire WorkelaCompen-
mlien,u provided for by section 37W of the Inbar Cade.for the performance of the,
-
wah for which 0k,permit k,issued,
❑I ban and will maintain Workers Compensation Insurance,as required by Section
37M of the Labor code,for the peCormanee of w.kforwhichthispermitislmued.
My Worker Competent Insurance carrier
Polley number
Carni .� t✓.O cy No„a 'll' ZDO,
CERTIFICATE OF EXEMPTION FROM WOR ERS'
COMPENSATION INSURANCE
fNk,secdon need net becomploud if the permit isf xonehundW dullaza(51p0
orlon.)
1 certify that in du performance of the work for which thin permit is Issued,I NW not
employ any person in any manner an as to become subject an the Wodare'COmpemadon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject in de,Worker's Compensation provisions of the labor Cada you must
.J O forthwith comply with such provisions.mis permil shall be domed rented.
ryVI.. CONSTRUCTION LENDING AGENCY
[r siteroby M.that them k,.eonNunfml lonamg.gemy for the performatux of —
a> the work for which this permit is Issued(Sec.3097,Cih,C.)
aQ Lenders Namc
=z Lenderl Addw
V I certify that 1 haw rod this application and suer that the above information is
U, current.I agme to comply with all city and county ordinances and sou laws relating to
O building construction.and hereby authorim Mpresenutim of th4 city to enter upon the
W &W.-mentioned pmpcny for infection purposes.
(We)agree to vat,indemnify and keep harmlem the City of Cupenina against
Cat Ilsbilimm,Judimems,costs and expenses which may In any way memo against mid City
U T in con orae ofz
of mis permit.
r1• PP Nf UNDS AND WILL COMPLY WI ALL NON-POINT Issued by: Date
:5
'11'6Re-roofs
SignuureofApp lk, Due
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant am orbandle hazardous material
LL defined by the Cu(I)mm Municipal Cade.Chapter 9.13,and the Health and Safety
e,section zss3z(a)7 All roofs shall be inspected prior to any roofing material being installed.
❑Y. u
Will the applicant or fumm building Occupant um equipment at devices which If a roof is installed without first obtaining an inspection,I agree to remove
It Innallou air conumi.nu as Med by me Bay Area Air Quality Management all new materials for inspection.
District
[3Y. u
ban mad the hazallommaterials mquirmommunder Chapterti.95 of she Califor.
n' th&SafctyCade,Ssnou25s05.23533 sed255 131`wde,galm mulfdc buimin9
d rrently hart•ten a that It k,my reamarm ity o y the aecupmt o(Ne
priyrmiauanccefaCcrtiOc 'Z SignatureGfApplicant Dale
Owner or authorized agent Date All roof coverings to be Class"B"or better