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10020035CITY OF CUPERTINO BUILDING PERMIT BUILDING ADDRESS: 19701 STEVENS CREEK BLVD CONTRACTOR: HENRY'S DESIGN & PERMIT NO: 10020035 SIGN CO OWNER'S NAME: YAMAOKA GEORGE 2018 EVANS LN DATE ISSUED: 02/05/2010 OWNER'S PHONE: 4087200600 SAN JOSE, CA 95125 PHONE NO: (408)269-0888 JOB DESCRIPTION: RESIDENTIAL El COMMERCIAL❑ LICENSED CONTRACTOR'S DECLARATION License Classy C_7(> Lic. # 1�� INSTALL ILLUMINATING CHANNEL SIGN rn Contractor Re bP-53 CO • Date V ' I hereby affirm thaa am licensed under the provisions of Chapter 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 Sq. Ft Floor Area: Valuation: $1500 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 APN Number: 31620083.00 Occupancy Type: permit is issued. APPLICANT CERTIFICATION I certify that I have read this application and state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED correct. I agree to comply with all city and county ordinances and state laws relating WITHIN 180. DAYS OF PERMIT ISSUANCE OR to building construction, and hereby authorize representatives of this city to enter upon the above mentioned property for inspection purposes. (We) agree to save 180 DAYS FROM LAST CALLED INSPECTION. 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 Issuep Date: with al l non -point sourc regulations per the Cupertino Municipal Code, Section 9.18. ((� 5 RE -ROOFS: Signature Date l 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. ❑ OWNER -BUILDER DECLARATION Signature of Applicant: Date: I hereby affirm that I am exempt from the Contractor's License Law for one of the following two reasons: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER 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 HAZARDOUS MATERIALS DISCLOSURE construct the project (Sec. 7044, Business & Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the declarations: Health & Safety Code, Section 25532(a) should I store or handle hazardous I have and will maintain a Certificate of Consent to self -insure for Worker's material. Additionally, should I use equipment or devices which emit hazardous Compensation, as provided for by Section 3700 of the Labor Code, for the air contaminants as defined by the Bay Area Air Quality Management District I performance of the work for which this permit is issued. will maintain compliance with the pertino Municipal Code, Chapter 9.12 and -1 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 -the-Health-&-Safety Code, -Sectio 505,-25533,-a n d-25534. permit is issued. Owner or authorized agent: Date: to 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 CONSTRUCTION LENDING AGENCY become subject to the Worker's Compensation provisions of the Labor Code, 1 must I hereby affirm that there is a construction lending agency for the performance of forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued (Sec. 3097, Civ C.) Lender's Name APPLICANT CERTIFICATION Lender's Address I certify that 1 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, ARCHITECT'S DECLARATION costs, and expenses which may accrue against said City in consequence of the I understand my plans shall be used as public records, granting of this ermit. Additionally, the applicant understands and will comply with all non-po source regulations per the Cupertino Municipal Code, Section Licensed Professional 9.18. �10 Signature Date CITY OF CUPERTINO SIGN CUPEkTINO PERMIT APPLICATION FORM Iuuz-00 3S' APN # Date: Building Addrggss: 1q1 ��IPVMS CrQ R vd , 4(AAo N Mailing Address (if different from building address): a C, Owner's Name: Phone #: �oVIA4ka. iob-i>o-o600xlo3 Contractor: Phone #: 5(0_91.w - Z(kq 6 Bey �P- ' I S -qv\ Co Fax #: 5b` 9 4 B. Contractor License #: Cupertino Business License #: Contact: Phone #: 6W —5D �cvt „ Fax #: 8w -140 _�XJ Building Permit Info: Bldg �_ _ Elect �� Monument ❑ Mounted on Building ❑ Residential ❑ Commercial Job Description: �sJAAl(k� AWA " t tS Ch 1AWe't lCO( Valuation (cost of project): V%0 Project Size: Express ❑ Standard ❑ Large ❑ Major ❑ Green Building: Please complete relevant portion of the Green Building Checklist & attach it to the application or if applicable, include in plan set & the sheet index. Revised 07/06/09 MM CITY OF CUPERTINO CITY OF CUPERTINO SIGN FEE SCHEDULE Quantity Fee ID Fee Description Fee Group Permit Type 1 SIGNDIRECT Directional B 1SIGN/RF Ground/Roof/Projecting Signs B 1 SIGNMASCK Master Plan Sign Check B 1 SIGNREWRKG Rework of any existing Ground Sign B 1 SIGNOTHER Other Sign B 1 SIGNREINSP Re -inspection Fee B 1 SIGNWNONEL Wall/Awning Sign, Non- Electric B 1 SIGNWELEC .: Wall, Electric E IESIGN Sign, Outline Lighting System or Marquee supplied from one branch E 10EAP5 1ESIGNADD Additional Branch Circuit on Same Sign, Outline System or Marquee E 10EAP6 1'ELCPLNCK Plan Check Fee E / 1 EPERMITFEE Electric Permit Fee E 1BCBSC - Cal Bldg Standards Commision Fee '-B ALL PERMIT TYPES 1BSEISMICOM Seismic Commercial B 1 BSEISMICRE Seismic Residential B ' 1TRAVDOC Travel & Documentation B I1 BUSLIC Business License B CCTV OF CUPERTINO Community Development 10300 Torre Avenue Cupertino CA 95014 Telephone (408) 777-3228 Fax (408) 777-3333 Building Department JOB ADD l��,,,�E,,,,S��S: PERMIT # OWNER'S NAME: kd. KAMc p 00 PHONE # GENERAL CONTRACTOR: Henalmxm U* co FAX # - U " I am not using any subcontractors: (6) ' Signature Date PIease check applicable subcontractors and complete the following information: Owner/ Contractor Signature Date SUBCONTRACTOR BUSINESS NAME BUSINESS LICENSE # Cabinets & Millwork Cement Finishing Electrical Excavation Fencing Flooring: Carpeting Linoleum / Wood Glass / Glazing Heating Insulation Landscaping Lathing Masonry Ornamental Sheet Metal Painting / Wallpaper Paving Plastering Plumbing Roofing Septic Tank Sheet Metal Sheet Rock Tile Owner/ Contractor Signature Date I M� r�J'1'IUtS IIIJhJJJ1"��'f1 - '_ l�i L'I: