05110159 CITY OF CUPERTINO ' baa•� +� f x }� ""
BUILDING DIVISION PERMITCQ ,R,d,GTORINF�O� RMr1,TI(1 '•f
,.F.. ••A' ;oval. Ydt^'a. .< B uµ.N Erse Z
BuIIDING ADDRESS: NIELSEN/AIRF CORP PERMIT NO.05110159
10680 D
R'S NAME: PERMIT ISSUE DATE
BYER PROP. 1601 GALVEZ AVE 11 /10/200S
NE: SANITARY NO. CONTROL NO.
(415) 643-8930
ARCNT 11INGINEER: BUILDING PERMIT INFO
qq ELECT PLUMB MECH
t � t �' u g�
j o O LICENSED CONTRACTORS DECLARATION IOb DeSCrt [IOIT Fr"'
F 1 Touchy dnom that 1 m licensed under provisions of CMpter 9(mmmancing P NmA
Iter Section
70lnBaf Divldon3ofde Bumessand Profaedmu Cade.And mYleenseu DF
mfalmmvandeO 8 $II C/O PER C.S .D. C pp05
iLicenxe Cors Lie.N_
3Fq Dam Canuauar
7W ARCallN mind
DECLARA ON fl�1f� ser Ar qqq
� I undewnJ my plana N,II be used u Public records 1{L/h:Y+111}f`I`)J/LIFT f�7�
A
Licensed Pmfewonal Q
U
b� OWNER.BUILDER DECLARATION
<4 1 hereby a1Rm Lha 1 m exempt from the Conuames License law for the \Y�
O O fallowing mason.(Section 101 L3,Businea And Profex,Ions Cade:Any city or county
a which requires a permit TO cmmruc,alar,balsam.demolish,or repair my structure $1200
prior in its issuance.aim requires te&Wiwi far such permit.Ole a signed miscreant
€< Thabo is licensed THIMUL to the Pmvimns of LIN CONMUsea License UW(Chapter 9 Sq.Ft, Floor Area Valuation
$ (commencing with Section 7000)of Division 3 of the Business And Prormsions Code)or
—
That he is exempt theefmm and the basis fm Lha alleged exemption MY vlalWon of
Section 70315 by any applicant for a permit subjects the Applicant to a civil penally of r 0 U Occupancy Type
not mom than live hundred d ra s(SS001.
0 I,asawoer of de property,army employees with wages a th,Irsvleeompensadon.
will do the wark.and thesmcmm Is notamnded aaRemd formic(Sec.7044.Buaneu RUi['Cd Inspections
'and Profession Code The Cannonade,I Immune Law coca not apply TA m caves C of q P
pmpeny who builds a impo+es thereon,and wM does such work hMself or Through his
we employee,pfavided that most improvements are not Intended vroRertd farsale IL
however,the building or improvement is mid within oro year of wmplvden.the awne-
Wilder MB Mme the burden of proving that he did rot build.improve for purpose of
ale.).
❑1,as avec ar the property.m c elusively mnuming with licensed announcement ut _
mawct the pmjca(Sec.7044,Bain.and Pmfadaa Cade:)The Conuamvh Li.
cause law does not apply to an owner of property-who builds or improves thereon.rod,
who mmracu fm auch projects with a conmmRa Imanad puraum.the Commences
Liana Law.
❑Ian esempl under gee .BhPCfa this maws
DATA
WORKER'S COMPENSATION DECLARATION
1 hereby Affirm under penalty of perjury one of the following decia done
I Mw and will.,Iowa aC.9nam ofCansmn a self-Insure few wark es Compen.
salon,u provided ran by Section 3700 of de Lahr Code,fm the performance of de
work for which this permit Is Wood.
❑1 ban and will maintain W.kce,Compensation an Issuance, required by Section
3700 of the Labor Code,for the performance of lite work for which this permit u issued. '
My Worker's Compenamon insurance artier and Policy number m:
Cartier.av� mar
��AS' /IVT. Policy No.:
CERTIFlCATEOFEXEMPTION FROM WO PERS'
COMPENSATION INSURANCE
mals sceman need notbc completed Time permit Is forone hundred dollars(111p)
or leu)
I wify that in the perro menm of The work Tar which this permit Is issued,I Nall not
employ any person in my mammraa As in becomes abject TO The Wmim'CmpensWon
Laws of Caifo.ia Data
Applicants
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m The Worker's Corn,cmdon provisions of the Labor Cattle,you masa
vJ 0 forthwith comply wim such provwans Or this permit 1111111 W deemed mvela d.
Zr~y., CONSTRUC ION LENDING AGENCY
l• I Manby AMM Tho Them is a construction lending&:easy for the perfumaue of
CL^ the wank for which this permit 4 Wiled(Sec.3097,CN.C.)
WM 0 Lender's Name ,
,7 Z Lender's Add.
U O I cenify that I Moe mad this applicator W suss That the above Information Is
i1.^ mann.i agree To comply with N city and county Ordinanm and auk laws relating in
O building construction.and hereby Amman representatives of this city to cnerupnn the
W above-mendoned property for inspection purposes.
(We)agree TA an,indemnify and seep harmless tie City of Cupertino against
r0./l liahilid menu,cgmmdexpan=which may In my way acaganslmid City
U Z Inco ue eof the leaning of me this pomp.
^ APPL ff EAST DS AND WILL COMPLY W1TLI ALL NON-POINT Issued by: Date �/ - ar r
SOURC�IE L - !/ 30
Re-roofs
Siggimmev Applican ontramr Dow
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will The applicant or future building occupant more or handle hazardous materia
deRucd by the Cupertino Municipal Code,Chapter 9.13,and The Health ad Safety.Section 23333U)? All roofs shall be inspected prior to any roofing material being installed.
❑ya 6No
Will the applicant or future building acempant vac equipment or novices which If a roof is installed without first obtaining an inspection,I agree to remove
.It huamoes Air conu.lnmts a donned by the Bay Area All Quality Mmgcmam all new materials for inspection.
Diawct?
❑Yes [dNo
a ad The huudmm materials requirements undcrChapter 6.95aftheCalifor-
nice Arm Cade, 'mts27303,21333md21334.lundamL dLhalftiebuilding
does I a M L and it 4 my responsibility TA notify the cceupmt or and
requi nu m tbeamphorseLuummoraCerullcateof m . Signature ofApplieant Date
Ow earatharixe ,gem D� All roof coverings to be Class"B"or better
* Community Development
10300 Torre Avenue
{ Cupertino CA 95014
Telephone(408) 777-3228
CITY OF Fax(408)777-3333
PERTINO .
Building Department
JOB ADDRESS: PERMIT #
io(oro s. 2e wzd 0 -- C/o
fZ
OWNER'S NAME: er ? PHONE #
GENERAL CONTRACTOR „ t.N FAX #
I am not using any subcontractors:
Signature Date
Please check applicable subcontractors and complete the following information
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 �/ a
Plumbing otis 3.et, Z� c�
Roofing
Septic Tank
Sheet Metal
$hept Rock
Tog .
Owner/Contractor Signature Date
CITY OF CUPERTINO
: P� �' REPIPE/SEWERS/MAIN SERVICE
CUPERTINO PERMIT APPLICATION FORM
APN # Date:
Building Address: N,
pL80 �uO'z
Owner's Name: yC.rN >-t_A1-�'N6' �^ Phone#:
1CL 12o> t1 - � --m t1-b2 -7t
Contractor: Phone: G,13_Qq-4o License#:
K �eW- V is ZA- Lo lo
o3 F
Contacts Phone: Cupertino Business License#:
t ti- 2A- Z3 s ol-
Building Permit Info: ^/
BldgEl Elect El Plumb R2
Job Description: t
Residential ❑ Commercial
Cost of Project:
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg. Permit Fees BUILDING
BPGAS Gas Piping System Fee PLUMBING
PPERMITFEE Plumbing Permit Issuance PLUMBING
BPREPIPE Re i eofFixtures PLUMBING
BPFIXTURE Pbl . Fixture PLUMBING
BPWSVCS Main Water Service PLUMBING
BPSEWER Sewers PLUMBING
BPSEWAGE Sewage Disposal PLUMBING
BUSLIC Business License BUILDING
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