05120001 CITY OF CUPERTINO
BUILDING DIVISION PERMIT MiRACTOR�INFQRMl"N �
BUIMINGADDRESS: ALLEN SIGNS INC Pte""D�0512OOO1
10877 N WOLFE RD
OWNER'S NAME: PERMIT ISSUE DATE
H. C. DUMPLING 1982 STONE. AV
SANITARY NO. CONTROL NO.
(408) 280-6500
ARCH17EC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
;oo ucENsaocoNrRAcroRSDEcuannoN Jab Description
(m I hemby affirm Out 1 am licensed under provisions of Chapter Y(commencing
`Z� with Section70(1U)of Divislon7.(Oe Buvness and Praressiens Code.ambo mYlucnseu
-Z. Inrrnmmearmerrne , $3� SIGN--INDIV. CHANNEL LETTER
p$z Lisnse Cli lJc.• (7 p
1 used a pr ,Q(!
ARCHTIECrS DECLARATIO
z< 1 understand my plans shall he used u public mord+ �®
JyU
s Licensed Pmfcssional ft/
5
OWNER-BUILDER DECLARATION
s�0Z 1,enemyafrom the 1Am I. ousinfrom IWComran.rs :A,cty. for IW
a O following mason(Schon 115 s ru Business and vefessinns Codc:Any oily m county ?006 $3000
3$ff whit,mquims a permit w construct,alcor.improve,dcmelLN,or rtpur any structure
:I< print m is issuance.also me,uims me applicant for such pemiue file a signed sulemcm
that the is licc.d pursuant to doe pm.isions of the Contractor'.License Law(Chapter 9 Sq.Ft. Floor Area Valuation
r�m (commencing with Section 7I)M)of Division]or the Businessmd Professions Code)or
that he u exempt therefrom and the basis for the alleged contraption.MY violation of
Section 7071.5 by any applicant for a permit mbjccts the applicant m a civil penalty of K-Ar ii:okCDarlcy Type
on,come tun five hundred dollars(3500).
0 1,u owner of Ibo pmpny,or my cmploym with wags u Iheb sole compensadon,
will dathcvon Code:
mommarscotNmndede awdotarsale(Sec.as Owneress
and Profession cede:The Contmcmrs License Law does nm apply lf an owner is _ Requited Inspections
man crewho WildsmimproveuN improve ands dcessuchwork hivaelfmthromchu
awneer,the uiprovidedmat such improwmenu am not snortedoro@red forore ora e,
builder,the Wilting or Improvement u sold within cote 5'u of sat ave for me o se of
builder wiB have tic burden of proving Nat he did not WiW.r improve for purpose of
sale.).
C]1.as owner or the progeny.am exclusively contracting with licensed contracrors Or
cam m ct One project(Sec.70Cd.Bush.aM Rofessi us Code:)The CWmates U.
cense Law does not apply to in owns of propenywho Wilds or improves Ihemon.and.
won conancca for such project/with amneaztor(s)licensed pursuant to the Cenvanors
Litton La .
❑Iameaemptand sec. ,B&PCfm Nismamn
Owner Date
WORKERS COMPENSATION DECLARATION
I hamby afrtrm under cul of perjury na or the following decimations:
have and will maintain a Cenifism of Consent to self-imam for WorkersC.mpen-
7037W.ftho
,U provided for by Section 77M of Ne labor Code.for Ne performance of the,
for which our permit is issued.
love and will maintain Workeh Compensation I....as myviroE by Section
labor Codc.fm the pedormana.fNe vmk fm which this permit u(vue&
orkers Canpeauaddononnnbamance carim and Poliry mumbo,er. .fYY)vI'C PolicyNo. LG�l/
CERTIFICATEOF EXEMPTION FROMWORKERS'
COMPENSATION INSURANCE
(Thu secdo.bond not be completed 0te permit is for.hundred&H.(SIN])
or lest)
I ce aify tWt in me Performance of ON work for which this Permit is issued,I,hall not
employ any person in any manecrm u In become subject to the Worked Compenamon
Laws of California.Daae
Applicant
NOTICE TO APPLICANT:If,aMr making this Ccnificae of Ercmpti.n,you should
bccmne subject m the Wmk s Compensation provisions of Ne Labor Code,you mm
.,O rOrh With comply with such provisions m Nu permit shall be deemed mwkc 1.
'z'-' CONSTRUCTION LENDING AGENCY
[—u i fur whalnm Nat mere W,ca (Seen lending agency fmm the perfonnana of
Q'i Lthe wore fur which this permit u Issued(Sec.5097,Civ.C.)
W� Q lenders Name
= z lenders Add.
U O 1 cmdfy dam I have rand this application and mm,Nu the above inforreatirn is
IL P correct.I agree m comply with all city and county ordinances and sub laws relating to
O U Wilding construction.anal hereby auumn,m mpmennu fives of this city m enter upon use
lihove-menudgmenropc a fond expenses
p enses purposes.
F gy (We)agme to save,indemnify and kap hatmless the City of Cupertino against
r/I in
of the coagand Of this permit. may in any way accrue againstsaid City
()z, A consequence of IW RSTAtrandng of Nu permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: 6�
Date
SOURC RUNDERSTANDS
t f Re-roofs
Sigmme of A�(Pli .women Data
\ AZARDOUS MATERIALS DISCLOSURE Type of Roof
Will Oe app tmfutum Wilding arupantame mhandichmudom material
u defined by Oe Cupenino Municipal Code.Chapter 9.11.and the Health and Safety
het@.
Zen by sssll(a)?
❑Yu All roofs shall be inspected prior to any roofing material being installed.
gI N.
If a roof is installed without first obtainingan inspection,I agree to remove
� Will tat applicant or rococo Wilding occupam use equipment.r Jevim which P g
District?
n hm,tdnus air contamimnaa ss defined by the Bay Amo Air Quality M...Ccmcnt all new materials for inspection.
t]Ya XNo
1 have mad One hvardamsmauriab mquimmenta under Chmserb.95 of the Califor.
ria HalthhSarmyCodc.Satoen505,M33 and 25534.ltmdcnsuM thaifte Wilding
does not currently how a u o nt.that it u my maponsibility m notify the arupant of the
myuirt wh moat Ipnmmiss.areof,Crdfiesuo'oeap Signature of Applicant Date
y
Omar on horn ,Sem Dam' - All roof coverings to be Class"I4"or better
CITY OFC-PERTINO
BUILDING DIVISION PERC�NTRACT�()ItINORMOIY
.�v '.., ill
BUILDING ADDRESS: ALLEN SIGNS INC 05120001
10877 N WOLFE RD PERM'rISSUEDATE
O"NER'S NAME:
H. C. DUMPLING 1982 STONE. AVE
SANITARY NO. CONTROL NO.
P NE:
(408) 280-6500
BUILDING PERMIT INFO
ARCHITECTIENGINEER: = 0'BLDG ELECT PLUMB MECH
iOp LICENSED CONTRACTOR'S DECLARATION y'+ ob Desc�tion
4 C 1 Mmby affirm Out 1 am liamed under nd linioru of Chip.,9(commencing
tJ with Section]WU)of Division7of NC Business and oPr�ofessium Cmw.toWmylitoweis SIGN--INDIV. rH
in full film,and,fife, eJ?)(_
Lic
Damnu Clatsz ARCHRECT'SDECLARATIO✓\ IAAI /aI
`� 1 understand my plans shall he used as public records JAN
:i U
s o y Liccru,I herepoi(by affirm
[I B I p r//fII ssll pp
OWNER-BUILDER DECLARATION [p07�W71® ypll [pj l9 pq kl
of Ihcrew alTrm Nat1exempt from No Contractor's :Any,enow La w.forthe laja®WV,p(
p o following mason.(Section](13 I.S.LBusiness and Pmfesdnn Code:Any city car county 3 O O 0
<m which b,,L—a permit m emmtmm,alma improve,demolish.or repair any ruueture
pnartoiks issuance.also laquires the applicant for such permit file a signed sutcmcm Valuation
-R< that heislicensedpursuanuo(be plavisloeofthe Connector's[3ccnxLa.(Chapter 9 Sq.Ft. Floor Area
y,0 wroun ming with Section 70](0 of Division 3 of the Business and Profession Cine).1
Wthat he is exempt thcmfrom and the basis for the alleged exempdon.Any violation of
Section 7031.5 by any applimmt for a permit subjccu the applicant to a civil penalty of r Occupancy Type
not marc than five hundred dollars($500).
0 I,as owner of the property or my employcas with wager as then rale a ampensadan,
will do the work,and Ne strucmm is not immnded or offered for sale(Scc.7W.Business Required Inspections
and Plafesdam Code:'The Canuaemr'i License Law docs not apply to an owner of -
pmpcny who builds or improve the,ron.and who docs such work himself ar thlaugh hix
n employ..provided that such improvements are not intended reoffered for sale.IL
bowevec the Wilding or improvement is sold within one year of mmplo ion.the owner-
' builder will have the burden of playing Nat he did not build or improve for purpose of
sale.).
0 1.as owner of the property,am a bulli ely con meting with licensed conuacmrs to
".."'A"
the project(Scc.7044,Busines and Prates!..Code:)The Contractor's Li-
cn
ce law don oat apply to an owner of property who Wilds or impnvos thereon,and
who contracts for such pmjeets with a contractor(a)licensed Pursuant to Ne Contractile-
License Law.
0 1 am exempt under Sec B h P C for this rtuon
Data
m
WORKER'S COMPENSATION DECLARATION
1 hereby aRmt under pemity of perjury one of the fallowing declamdom:
0 I hire and will maintain a Ce,ofeato of Consent in self-insure for Worker'sCompen-
sation,as provided for by Section 3700 of the Labor Code,for'be perf!mance of wo
W
ork(or which this permit is issued.
❑1 have and will maintain Worker's Compensation Inurantt,as required by Section
370(1 of the Labor Code,for the performance of Ne work for which Nu permit u issued.
My Workers Componsxtio t Imuran¢o ria and Policy number am:
Cartier.^f'Pa7.FY1� S - Polity No.�y/�.a 0
CERTIFlCATEOF EKEM MON FRO WORKERS'
COMPENSATION INSURANCE
(This merino Med nut Weamplcmd if the permit is forum,hundred dollars($10(1)
or less.)
I cenify that in the perfamuncc of the work Tor which this permit is issued.I shall not
employ any person in any mannersin as to become subject to Ne Workers Compensation
Laws of Califamia.Dam
APPlicam
NOTICE TO APPLICANT:IL after making this Cenifom of Exemption,you should
become subject o the Workers Compencati,n previsions of the Labor Code,you must
.Jz forthvnth comply with such provisions or this permit shall h,deemed mwrked.
Z
`z, CONSTRVCr10N LENDING AGENCY
[-r Ikmhy afion Nm Nem iso construction lending agency fm the porform.n.of
(L' 7 the work(ser which this permit is issued(Scc.3(197,Civ.C.)
W�Q Lcndcrs Name
= z Lcndcrs Address
U 0 1 certify that I have read this application and sum that the he.mfotmadun is
L, comer.I agree to comply with e11 city and county ordinances and auto laws elafng to
0U building conswction.and hereby auNodw representatives of this city to cner upon Oc
r Watm
om- entiope
ned pmpony far insction purposes
CL (We)agree to save,indemnify and keep harmless the City of Cupcnino against
rF-t N liabilities.judgments,cut"and calico.which may in any way seem.against saidCity
U in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POIN'r Issued by: Date
SOURCR ULATIONS
Re-roofs
Signutim.f Appliea^ 'annow Dau
AZARDOUS MATERIALS DISCLOSURE - Type of Roof
Will thc adpf m.,fuwm building owupamuorc Orionis,hicardaus ma¢nal
as defined by the Cupertino Municipal Code.Chapter 9.12.and thc Health and Safety
Cno.Stition25532(a)+ .. All roofs shall be inspected prior to any roofing material being installed.
❑ a
Yes gf Nu
Will the applicant or future building occupant us,equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Disui<t7
❑Yes 'KN.
1 have mad No rima doto maenals requircmcnu under Chapmr6.95.(the Calif.,
nix Health d:Safety Cade,Sections 35505.25533 and 25534.1 undemaM Nat if the building
does not currently have a¢nano that it is my mspomihility to notify the occupant of the
reyvire '�whihmustx.ptetpnnra,irsaane,nrac,rdfeenracnpj7 Signature of Applicant Date
•_� 1 y t U All roof coverings to be Class "B" or better
Owner or authoru agent Da¢
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CITY OF CUPERTINO
SIGN o f �'-o azo
CUPEI�TINO PERMIT APPLICATION FORM
APN# 3 t 6 —OJT _ OJ / Date: '
Building Address:
IDS-77 A). U2e6Ce
Owner's Name: IPhone #:
14 cl;n -sG
Contractor: I/ License#:
S nC. U
Contact: U
J' Ph #:
or we Z& 456
App licant/Contractor:
Building Permit Info:
Bldg Elect✓ Plumb Mech
Job Description: —! n Vi U ChAnhd (&tW,4- s-
Residential: ommercial:
Sq.Ft. Floor Area: q t
Architect/Engineer: Cost of Project:
3, —
Type of Construction: Occupancy Group:
Qty. if
A licable Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
M
BSEISMICOSeismic Commercial BUILIDNG
EPERMITFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Si s Add Branch ELECTRICAL
BREMSIGNS Rmdl Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG