11090094CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10120 N DE ANZA BLVD
OWNER'S NAME: ROMAN CATHOLIC WELFARE CORP OF SAN
OWNER'S PHONE: 4082526441
❑ LICENSED CONTRACTOR'S DcE�CLARATION
License Class 6 --/Lic. # 7 ��
Contractor °W D W Date r
I hereby affirm that I am licensed carder the provisions of hapter 9
(commencing with Section 7000) of Division 3 of the Business & Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
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.
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
permit is issued.
APPLICANT CERTIFICATION
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 and state laws relating
to building construction, and hereby authorize 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 may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulationsjer=fligCupertino Municipal Code, Section
9.18.
Signature _- Date
❑ OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
I hereby affirm under penalty of perjury one of the following three
declarations:
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.
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
permit is issued.
I 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 to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CERTIFICATION
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 and state laws relating
to building construction, and hereby authorize 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 may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
CONTRACTOR: MID WAY SIGNS PERMIT NO: It 090094
3290 BASSETT ST DATE ISSUED: 09/14/2011
SANTA CLARA, CA 95054 PHONE NO: (408)982-9696
BUILDING PERMIT INFO: BLDG ELECT r PLUMB'
MECH F RESIDENTIAL r COMMERCIAL f—
JOB DESCRIPTION: ST. JOSEPH CHURCH - CONSTRUCT NEW ILLUMINATED
MONUMENT SIGN
Sq. Ft Floor Area: I Valuation: $4900
APN Number: 31626097.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Issued by:
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
HAZARDOUS MATERIALS DISCLOSURE
I have read the hazardous materials requirements under Chapter 6.95 of the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a constructionJI(ding agency for the performance of vmrk's
for which this permit is issued 97, Civ C.)
Lender's Name
Lender's Address
ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Licensed Professional
Signature Date
CITY OF CUPERTINO
V- M-9 I FEE ESTIMATOR - BUILDING DIVISION
19
ADDRESS: 10120 n. de anza blvd
DATE: 09/14/2011
REVIEWED BY: bobs.
APN:
BP#:
"VALUATION: 1$4,900 —�
'PERMIT TYPE: Building Permit
PRIMARY Sign
USE: g
PENTAMATION 10EAP5
PERMIT TYPE:
WORK
construct new illuminated monument sign
SCOPE
SIGN TYPE
FEE ID
QTY
SIGN FEE
Ground Sign
1SIGNGR/RF
1
$327
TOTALS:
$327.00
# Branch Circuits 1 $44.00
i.1r, :tl. r•:';%r,%( J`:'....
�'1%!iti,%. ��C'i7Ji< F''(':
IESIGN Elec. Permit Fee: IEPERMIT
Other Elec. Insp. 0.0 $44.00
W 'p .
NOTE. This estimate does not include fees due to other Depts (i.e. Public Works, Sanitary Sewer District, School District, etc.).
These fees are based on the Preliminary information available and are only an estimate. Contact the Dept for addn'l info.
FEE ITEMS (I ee Resohrtion 11-053 E '. 7/UI I)
FEE
QTY/FEE
MISC ITEMS
Suppl. PC Fee: 0 Reg. 0 OT
0.0
1 hrs
$0.00
Permit Fee:
$327.00
Suppl. Insp. Fee:G Reg. 0 OT
0.0
hrs
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Work Without Permit? Q Yes Q No
$0.00
Sign Master Plan: 0 Yes Q No
$0.00
Travel Documentation Fee: ITRAVDOC
$44.00
Strong Motion Fee: 1BSEISMICO
$1.03
Select an Administrative Item
Btdg Stds Commission Fee: IBCBSC
$1.00
SUBTOTALS:
$461.03
$0.00 TOTAL FEE: 1
$461.03
Revised: 09/02/2011
CITY OF CUPERTINO
FEE ESTIMATOR - BUILDING DIVISION
ADDRESS: 10120 n. de anza blvd
DATE: 09/14/2011
REVIEWED BY: bobs.
APN:
I BP#:
*VALUATION: 1$4,900
*'PERMIT TYPE: Building Permit
PRIMARY Sign
USE.
PENTAMATION 1 CEAP5
PERMIT TYPE:
WORK
new illuminated monument sign
�construct
SCOPE
SIGN TYPE
FEE ID
QTY
SIGN FEE
Ground Sign -1
1SIGNGR/RF
1
$327
TOTALS:
1
1 $327.00
1
# Branch Circuits 1 $44.00
IESIGN
Elec. Permit Fee: IEPERA4IT
0"I'lev -,H,.�,j!
Other Elec. Insp. L2.0j $44.00
NOTE. This estimate does not include fees due to otherDepts (i.e. Public Works, Sanitary Sewer District, School District, etc.).
These tees are based on the nreliminary information available and are onlv an estimate. Contact the Dent for addnl info.
FEE ITEMS (Fee Resolution 11-053 & 7111LI)
FEE
QTY/FEE
MISC ITEMS
Suppl. PC Fee: 0 Reg. 0 OT
1 0.0
hrs
$0.00
Permit Fee:
$327.00
Suppl. Insp. Fee: (F) Reg. 0 OT
"00
hrs
$0.00
PME Unit Fee:
$44.00
PME Permit Fee:
$44.00
Work Without Permit? 0 Yes E) No
$0.00
Sign Master Plan: 0 Yes (j) No
$0.00
Travel Documentation Fee: ITRAVDOC
$44.00
Strong Motion Fee: IBSEISAffCO
$1.03
Select an Administrative Item
1
Bldg Stds Commission Fee: IBCBSC
$1.001
SUBTOTALS:
$461.031
$0.001 TOTAL. FEE:
1 $461.03
Revised: 09/02/2011