04010078 CITY OF CUPER NNO
BUILDING olvlswN PERMIT CONTRACTOR INVORIVIATION a•
aulLDInG An '4nDDaFss: NIELSEN/AIRF CORP PERMIT N°04010078
ER'S NAME: PERMIT ISSUE DATE
PHONE: SANITARY N0. CONTROL NO.
ARCHMIC(ENGINEER: BUILDING PERMIT INFO
BLD° ELECT PLUMB MECtI
uOJobDescri Description
0 LICENSEDCONfRACTOR'SDECLARATION
F I hereby air,,.that 1 am licensed under provisions or Chapter 9(commencing P
`f with Section7MB of Division 3 of the Busincsa and Professions Code.and my license is
in mB tone and direct
Licence Class Lit.A REVISION--IN HOUSE USE ONLY
j q z
�c Dam Camnmor NEW PERMIT ISSUED/ORIG. #03100026
�j ARCHITECTS DECLARATION
e� 1 understand my plana shall W used a public records
WV
c Licensed Pmfcssional
3 OWNER-BUILDER DEC.Cent.ON /
+� 1 naso affirm that 1 ore ewmpe from Ne Comns Co License Law for the `
i 2O following rcuaa Permit
t 9(131.4 Business and improve,
demolish.
Code:Any city Or roomy �1
5$m which rets ham a permit to also paresconsviaL,the applicant
improve,demolish,or mash any tatueurt v
Zi poor toi¢iensedi ismoutin the prevision O for such penniuocamic Law(Chagned mem
O
,hot
mencing wit pursuant mthe of Divisnsnr the Comranssa Liana Law(Charter Sq.Ft, Floor Area �," Valuation$32
ej$ (commencing with Scaion7(gN))of Division 3 o NC Business and Professions Co�c)ot
Net he Is exempt therefrom and the buss for the alleged exemption,Any violation of
Section 7031.5 by any apPlicantfor a permluubjects the applicant Ur a civil penalty of APN Number OMupancy Type
not mon Nan Bvs hundred dollen($500).
❑1,u owner of the property,Or my employees with wages as their sole compensation, 35908005 . 00
will do the work and the structure is not innndcd or offered for solo(Sec.9614.Businm Required Inspections
and Pmfeuim"Code:The Contractors Lt..Low doss not apply to an owner or q P
progeny who build.or improve.Nereon,and who dos each wmkhimul(orNmugh his
Own employees,provided that such improvements are not immnded oronered formic,If,
however,the building or improvement is sold within one you of completion,the owner.
builder will haw the human of proving Nn he did not Wild or improve for putpos,of
I1,us owner of Be property,am exclusively contracting with licensed contractors to
strvet the project(Sec.Tom,Business and Profusion$Code:)The Convactor'a LI-
cense Law does not apply to an owner of propcny who Wilds or improves Norton,and
who contracts for such projects with a conmacuu(s)licensed pursuant to dee Contractors
'Kahn Law.
❑lam exempt on ac. ,B&PCRrlhiammon
r am
WORKER's COMPENSATION DECD ION
1-by if,.under pemlty of perjury one or the owing elucidation
❑l have and will mainuin a Cenirinu of Consenuo Ulf-Insure for Worker's Compen.
mann,u provided for by Section 3700 of Ne Labor Code,fm du Perfarromen of the
work rot which this permit is issued.
1 haw and will maintain Worker's Compensation Insurance,as nyvired by Section
3700 o1 Ne labor Code.for th performance Of due work for which this Permit is iaued,
My Workers Compeuaion Insun is carrier end Policy number art:
Cartier. Policy No.:
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSU RANCE
(Thu aceinn need not W comPlemd time,Permit is ranee hundred Collars($1110)
or leu.)
I certify that in the pamm rmo.of Ne wart for which this Permit is issued.I shall nut
employ any Person in any mmner an as or become subject to too Workers Compenu0on -
Law.of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this CeniEcam of Exemption,you should
become subject to the Workers Compensation provisions of the Ichor Crude,you must
.,O forthwith comply with such Previsions or this Permit hall W deemed invoked.
Z y CONSTRUCTION LENDING AGENCY
[—i I henhy alrnm that Nen is a construction lending agency for Ne iterformmce of
CL > dee.,it(a,which Nis permit Is ivued(Sec.XM,Civ.C.)
lf] Q Lenders Name
Dz Lenders Address ..
U Q 1 cenify Nat I have rod Nis application and sum that the above information is
1L t" correct.1 Agree to comply wide all city and County ominatmo and sure laws relating to
0U building construction.and hereby suthorim inpmsenutiws of Ni.city to enter upon the
W ahovmmcmioncd property for inspection purposes.
(We)agree to saw.indemnify and keep hornlessthe City Of Cupertino against
N Iiabilide..jndgments,coats ande Imps which may in any way accrue agatmaresid City
U z in conu9uene..(the granting of this Permit
APPLICANT U STANDS AND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE RE N5.
�°/:/� Re-roofs
Signior of ApplicamOCOmmator Dam
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF
Will Nr.applicant or future building Occupant store m handle haysrdouc material '
u do
by the Cupertino Munyy'pal Code.Cho Let 9.1],and the HOMO end Safety
e,Secunn lss3g(a)? a�// All roofs shall be inspected prior to any roofing material being installed.
❑Yu ry'///,QWt��
Will the ePPlice rur rnwte bpildins uapPam pY ewmmem rur device.wMrh If a roof is installed without first obtaining an inspection,I agree to remove
emit hn4rdnus air conuminanu tread by the Bay Area Air Quality Management - all new materials for inspection.
District?
Yes
IhawmWdeeh Nous materials reyuinments under Chapter 6.95 of the Califon 7
nia Hcalds&Safety Code,Sections 25505.25533 and 25534.1 understand dew if he Wilding v -
does twi c rely haw a¢nano that it is my responsibility m noufy,Ne a.'cup ore of the
myuinmcts khmus .Trlprior avanaOra crrdeoamrur r er. Signature of Applicant Date
y ma iL
Owner or apdeeriv ascot Dam All roof coverings to be Class"B" or better