04010137 (4) CITY OF CUPERTINO T�1� ' zT "XI
BUILDING DIVISION PERMIT �ON` P.ACC ORiINIiOR-MATION.-'.
BUILDING ADDRESS: CAL—NEON SIGN PERMITN04010137
ERS NAME: PERMIT ISSUE DATE
PHONE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
H00 LICENSED CONTRACTOR'S DECLARATION
U F I terms,.ffirm that I am licensed under pmvedoes of Chapter 9(commencing Job Description
ap`j with 5cction]"I of Division Sof the Business and Professions Code,and my license is �'� aA ��®
Ze' in full force and effect SIGN--LANG' S CAFE ,i�
License C ¢ �y Lic.M
Date Conran iV 0 2004
s£�, ARCHITECTS DEC RA ON MAR
Y W U 1 understand my plans shall he used as public records
a
u•vt Licensed Professional
jg OWNER-BUILDER DECLARATION BUILDING
81 i N I hereby affirm that 1 em exempt from the Conlmcmr's License Law for the
Hi following nouns.(Section 7131.5,Business and Professions Code:Any city or county
K m which requires a permit to construct,abet,improve,demolish,or repair any Structure
prior its issuance,also requires the applicant for such Permit o File a signed statement
that he is licensed puravanuo the provisions or the Conlrmrtur's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
(commencing with Section 7")of Division 3 of the B usincss and Professions Code)or
Nat he is exempt therefrom and the basis for the alleged exemption.Any violation of r,uvww.,�.a..�
Section 7031.5 by any applicant for a permit subjects Ne applicant n a civil penally of 3SG Wl]tpJNllWef00 OCCU araC Type
not more man fivs handled dollars($5Bo>.. P Y YP
❑1,as owner of the property,or my employees with wages as shelf sole compensation, -
will do the..,it.end the swctu ,is not intended or offered for sale(See.7044,Business
and Professions Code:The Contractor's License law does not apply to an owner of Required Inspections
property who builds orimpreves thereon.and who dee such work himselfor through his
own employees,provided mat each improvements are Out intended proffered for sale.If.
however,the building of improvement is sold within arta year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner of me property,am exclusively contracting with licensed contractors to
convect the project(Sec.7044,Business and Professions Cade)The Contractors Li.
cense law does not apply to an owner of property who builds or improves menton,and
who contracts for such projects with a contractor(&)licensed pursuant to the Contractor
License Law.
I ser exempt under Sec. B A P C for this reason
er Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of 0te following declarations:
I have and will maintain a Certificate of Consent to self-insure for Workers Compete
s ion,Or provided for by Section 3700 of the Letter Code,for the performance of the
work for which this permit is issued. - -
have and will maintain Workers Compensation lasunnce,as required by Section - -
300ofthe Labor Cotle,for the performance ofthe work for which this permit is issued. ,
al Workcff/¢Cpam�p{enatio Insusanee carrier and Policy Matter am:
Cartier.I/V 2, ZOP13 Policy No.:✓TRr
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the permit is for..hundred dolma($100)
or less.)
1 certify that in the performance of the work for which this permit is issued,I shall not
employ any person in any manner so as to become subject o the Workers''Compensation -
Law.of California.Data
Applicant _
NOTICE TO APPLICANT:If,after making this CeniOcaue of Exemption,you should
become subject to the Worker's Compensation previsions of the Datum Code,you must
.JO forthwith comply with such provisions of this Permit shall be deemed revoked.
zt h CONSTRUCTION LENDING AGENCY
[r I hereby affirm that then is a constrvction lending agency far the Performance of
ai ti the work for which this permit is issued(Sec.3097.Civ.C.)
fL1 Q Under's Name
z Lenders Address
V O 1 eenify that I have read this application no stem that the above information is
17. F correct.I agree to comply with all city and county Romances and auk laws relating to
0U building convection,and hereby authorize reprosemadves of miss city to enter upon the
W ffiove-cs,judnedproperty for dexpenses purposes.
gy (We)agree to save,indemnify and keep harmleu:he City of Cupertino against
fq
in
enceofthee9snand expenses which may in any way secure against said City
A APPLICANT
of DERST ing S A permit.
t� APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SC&AM REGULAT
CAL 4 eeeel Re-roofs
�Prgnatum of plicaHAZARDOUs MATERIALS DISCLOSUR ate Type Of ROOF
Will the applicant or future building Occupant m ban le hav4rd9u.material
as coined by the Canaria.Municipal Code,Chapter 9.12,and the Health end Safety
sectienzss32(a)7 All roofs shall be inspected prior to any roofing material being installed.
W
' W ❑Yes ri1 Nu
If a roof is installed without first obtaining an inspection,I agree to remove
Will the applicant or future building occupant use equipment or devices which P g
cmb haaardous air con ealments as darned by the Bay Area Air Quality Management
District? all new materials for inspection.
❑Yes
I have mall the havNtmsmaterials requirements under ChaPter6.95 of dm Califon.
nia Healer!¢Safmy Code.Sections 25505,25533 and 25534.1 undcmlaod that VETO building
doea not et oemly have a R...4 thm it is my responsibility m sully the occupant of the
requimor whiehmastbem I "at C.mfie.a I Otcupoincy. Signature of Applicant Date
e,ar aathonznd gen, YDat All roof coverings to be Class "B"or better