10010005CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10555 S DE ANZA BLVD STE 125
CONTRACTOR: SUCCESS GRAPHIC SIGNS
PERMIT NO: 10010005
OWNER'S NAME: HUNTER PROPERTIES INC
1744 QUEENS CROSSING DR
DATE ISSUED: 01/04/2010
OWNER'S PHONE: 4083505360
SAN JOSE, CA 95132
PHONE NO: (408) 306-9521
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class
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MECH RESIDENTIAL COMMERCIAL
Contractor CJ,Sr� (7f'�llate
I hereby affirm that I am licensed under the provisions of Chapte 9
JOB DESCRIPTION: INSTALL (1) SET INTERNALLY ILLUMINATE CHANNEL
(commencing with Section 7000) of Division 3 of the Business & Professions
LETTERS
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.
Sq. Ft Floor Area:
Valuation: $2000
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.
APN Number: 35918058.STE 125
Occupancy Type:
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
PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Addition 11 the applicant understands and will comply
with all non -point regulations r the Cupertino Municipal Code, Sectio
9.18.
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Issued ¢.✓� -- y— "- , Date��
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Signature Date
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of
installed without first obtaining an inspection, I agree to remove all new materials for
the following two reasons:
inspection.
1, 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,
Signature of Applicant: Date:
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self -insure for Worker's
I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation, as provided for by Section 3700 of the Labor Code, for the
California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain
performance of the work for which this permit is issued.
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
I have and will maintain Worker's Compensation Insurance, as provided for by
Safety Code, Section 25532(a) should I store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Health & Safety Code, Sections 25505, 25533, and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of Califomia. If, after making this certificate of exemption, I
Owner or a or' .7t _ t 1 D,/ � J
become subject to the Worker's Compensation provisions of the Labor Code, I must
Vt/lJ Date: ` T
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is
for which this permit is issued (Sec. 3097, Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating
Lender's Name
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
Lender's Address
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
ARCHITECT'S DECLARATION
with all non -point source ions pe a Cupertino Municipal Code, Section
I understand my plans shall be used as public records.
9.18. � -
1 , / ( �t (Ior
Licensed Professional
Signature!/W Date