03110127 (4) Cl'CY Ole CUPER'TINO A �"" """ "^��
Him 1,1111 NG Drv1s1oN PERM G0NTRxACTORrINT.0I2MA: N
BUILDING ADDRESS: XL CONSTRUCTION PERMITN003110127
ID991 N
SR's NAME: PERMIT ISSUE DATE
AR ONE CREDIT UNION 1500 BERGER DR 11/21/2003
NE:
SANITARY NO. CONTROL NO.
(408) 271-2425
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
loo LICENSED CON'TRACTOR'S DECLARATION lob Description
m 1 hereby affirm that I am licensed under provisions of Chapter 9(commencing
�zE with Section]t](1B)nf Division Sof the Busing.rd Professions Cnde.and my license is
<<.�m in full to deffea 1
Iqz License 1(a ur.n SIGN
Date I Cc c� b
s ARCIIITECTS mi-ARATION
Kadcrsund my plans shall M used-fixe public acmda
>au
a y Licenser Pmfcssional
� OWNER-BUILDER DECLARATION
Comments
om enhe
.�a f I hereby affirm that 1 1. exempt(nate the Cssions is Cods,Any c Law far my
o o which ng reason.(Schon]11]15,Businer, and improve.
da io i h.oAny city to county
m which rtquires a permit m cnnmhiu.alter,improve.Jemnlish,or mpvr any structure $2000
°iy poor m its issuance,also requires the applicant for such perm i t to file a.signed statement S Ft. Floor Area Valuation
a that he is licensed pursuanttothe previsions OfthicCommtom,License Law(Chepter9 Sq.
Z" (Commencing with Section]000)of Division 3 of the Business and Professions Code)or
that he in exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for A permit subjccta the applicant o a civil penalty of 3 A NQdLSi5orO 0 Occupancy Type
not more than five hundred dollars(SSW).
I,As owner of the property,or my employees with wages as Neil sole compeuaetion,
will do the work.end the swnure is not intended or offered for sale(Sec.?O14,Business RC uICCd IfJ6 CChOrIS
and Pmfcssions Code:The Convenor's Licence Law does not apply to an owner of 9 UJ2 1pi P
property who builds ar improvrs themon,and who dmi smIn work dao elror though his
Own employees,pnvidcd that such improvements are not intended or offered for sale.If, 7
however,the building or improvement s sold within one year of completion,me owner /� 7
builder will have Ne burden or proving that he did not build or improve for purpose of Y
❑ 1.roownerofct ppopen, with licensed eonuanors l-
eonsuva does notaSec.]044,wnerossand professionsCode:)oe:)The Convamon'sLi-
who Law drcsnotapply man with
ofpnopcny who buildsorimproves thereon.and
whocontractsLaw.for such projects with a canvaaor(s)licensed pursuant to d¢Conoactora
License Law.
❑lam exempt under See. .B&PCfor this reason
ten Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penalty of perjury one of the following declarations:
❑1 have and will maintain a Cenifirate of Consent to ulr-insure run Worker's Compcm
nation.ss provided for by Section moo of the labor Code,for me performance or the
work for which this Report is issued.
❑1 have and will maintain Worker's Compensation insurance as required by Section
3700 or the labor Code,for me performance of me work for which this permit is issued.
My Worker's Compensation
�Insurance
�carrier and Policy nNo nuumbbeer'are:
Carper:)?au.nE ICATE OF E%E�IPnONFROM ORW KERSS �� D
YCOMPENSATION INSURANCE
prox section need not M completed if the permit is for one hundred dollars(SITS))
or less.)
1 anify that in the performance of the wink for which this permit is issued,I shall not
employ any person in any manner so u in become subject to me Wa keri Compensation
'Laws of California.Data
Applicant
NOTICE TO APPLICANT:IL aper making this Certificate of Exemption,you should
become subject to the Workers Compensation provisions of the labor Code,you must
Z forthwith comply with such pmrisloos or this permit Shall M deemed revoked.
ZC�
y CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agmxy for the performance of
x Y the work for which this permit u issued(Sec.3097,Ci,CJ
IA Lendcis Name
= Z loaders Address
U CD L amity that I have read this application and sour,that the above infotma,iun is
I,. f-' correct.L agree m comply with all city and roomy oNinanco and so¢laws prating to
�U building conswction,and hereby authorim mprcieton Yes of his city to enter upon the
r W above-mentioned property for inspection puToses.
(~ G (We)agree to ave,indemnify and keep harmless the City or Cupertino against /
U1 liabilit id3,judgmcnf�h3-ipso and expenses which may in any way Archie,against said City S 1
U r inAPPLICANTeON B SDS AND^ANToril. sWILL COMPLY WITH ALL NON-POINT Issued by: Date I(
SOUR GO �
Signa re pprcant(Contrartor IDal
i►IZI �'� Re-roofs .
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will me applicant ser future Wilding Occupant store or handle haiudous material
az defined by the Cupenim Municipal Code.Chapter 9.11,and the Health and Safety
Adhi'dr.Section 15532(.)? All roofs shall be inspected prior to any roofing material being installed.
�Yca �No
Will me.applicant future building t use a hit or drmeea which
If a roof is installed without first obtaining an inspection,I agree to remove
pp g occupan quipmc
mit hreandous air contaminants Ac refired by the Bay Arca Air Quality Managcmonl all new materials for Inspection.
D'svin?
l7 Ycs
I have read the haraNnus materials requiremcros under Ch.por 6.95 of me Califon
ria Hcalmth Safety duns25N15,25533and2534.1unW'rs.dthatiftM Wilding
dos not current t an thatit is my respomihility m notify tM a upmt nrthc
noorcmenUs is pnorwiaaam r>camfiramorarar D.3 Signature of Applicant Date
Ow orireJ agate o te All roof coverings to be Class "B" or better
CITY OF CUPERTINO
G SIGN
IRCUPEf�TINO PERMIT APPLICATION FORM
APN # Date:
Z b3
Building Address:
/0 9q 13
Owner's Name: Phone#:
Contract License#: (oq 7
Contact: Phone#:
�V?i 400 5q L - Z07
Applicant/Contractor:
Building Permit Info:
Bldg Elect Plumb Mech
Job Description: ^�
Residential: tJ Commercial:
Sq.Ft. Floor Area: $/Sq.Ft.:
Architect/Engineer: Valuation:
Type of Construction: Occupancy Group:
cJ � `
Qty. if
A c ble Fee ID Fee Description Fee Group
BENERGY Energy BUILIDNG
BPERMFEE Bldg Permit Fees BUILIDNG
BPLANCHK Plan Check Fee BUILIDNG
BSEISMICOM Seismic Commercial BUILIDNG
EPERMTTFEE Elect Permit Issuance ELECTRICAL
BREMSIGNAD Rmdl Signs Add Branch ELECTRICAL
BREMSIGNS Rmdl Signs, Marquee ELECTRICAL
BUSLIC Business License BUILIDNG
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