04070062CITY OF CUPERTINO
;t.a�waw,%;r^" ° ''��''jj^' ' •'
�ri�CONTRACTOR`iRio A-•n-QN "':
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
NIELSEN/AIRF CORP
PE ""04070062
OWNER'S NAME:
PERMIT ISSUE DAM
AUTOP
14,12OL
E:
SANITARY0. NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CON RACIOR'S DECLARATION
lb Description
oP
1 hereby of iren that I am Iimnsed under provisions ChuN e, 9 (commeneing
with Sall )of Division laf Ce Butinsmand Pr Code. arta my Ikeuc is
d —O
TI --OFFICE SPACE/WORK SPACE/SINK
LkcmeR"` Lm..
Dam T (��Conuecmr
A CHILCLA ATION
used
l underetglnd pyp aalWl he ecdupuhlie rgWrda.
I uua
�C l
Licensed Pmfeam0"1
OWNER -BUILDER DECLARATION
1 hereby adore that I em "empr from Me Convenor's License Law for the
following reason. (Section 71171.5, Business and Profession, Cade: My city or county
which requires a Permit m construct, altar, improve. demolish, or repair any structure
Goo
prior m i0 iaswnee, atm rcqumes the applicant forauch permit m rile asigncd statement
Sq. Ft. Floor Area
Valuation
thathelauccosedpununtmthepmvisimunfthoCanummr',Uccnmlaw(Chaptu9
(commcaing with Snedon 7000) of DiAmort 7 of tiro limineuand Profaasku Cade) err
But he Is statecraft therefrom and Ce bub far the alleged emmpdon. Any violation of
3 5dflt)1'RM30cT0 0
Occupancy Type
Seem. 7071.5 by any appli.1 fora permit subjects the applicant m e civll Penalty of
not mom than 0w bmldrtd dollars (5500).
0 I, u ower of dm pmpmy, m my employm withwetu a Cob mle mmpemdm.
Required Inspections
ee
will do the work, and theeMmcture is notimmnded oroBered fonalc(Sm. 70th, Business
and Preff mmru Code: The ConuacmYa License law dnot apply m an owner of
9 P
property who builds or improves earean, end who dna such work himself ser thmugb his
own emptoym, provided that such improvements am net intended OraBvN fuck. if,
however, the building or Improvement is mid within one year of compiedon. Ce Owner.
builder will have the burden of proving That he did nu build or improve for purpose of
calm.).
0 1, u owner of me property. am "elusively canuaNng with licensed contraction to
FIN .
aN Cade:) The Cwtrmmrs U.
camwn du project (Smapply
SLE®
of who and
cease law dm not apply m as owner of properly who Milds or improwa Centro. and
o an ownBuser property
who contracts for such projects withaeonwcror(s) licensed punwnl m Ce CContractor'Contractor'Contractor'Licensense
"e Law.
❑tem"emptund�See .BhPCfor Cbm�on
APR r3
1U�5
Owner Dam-
WORKER'S COMPENSATION DECLARATION
I hereby of rat under penalty of perjury am of Ce following dalantionf:
r
Mw and will maintain a Certificate ofConaent m self -insure far Workela Cornish.
on, as provided fu by Sudan 7700 of the labor Code, for the performance of the
YYFGGGJJJ
work for which this permit la issued.
0 1 now and will maintain Wortrls Compensation Insurance, u required by Semon
'
7700 of Ne labor Code, for the performance ofthe work for which this permit is issued.
My Worker's Con pen Non Insurance artier and Polie, number an:
.
Cacti I. a3. Ile, Nr.:
CERTIFICATEOFEX ON FROM WORKERS'
COMPENSA INSURANCE
Ono mcdm neN not heeamplemd if the permit isforaahundm l dollars(SIM)
or less.)
I certify that in the performance of the work for which this permit is issued. I shall not
employ any person in any manner an as to become subject to the Workeri ComPenadon
Laws of Califomie. Data
Applicant
NOTICE TO APPLICANT: If. after making Cb OwiBau of Exemption, you should
become subject at the Worker's Compensation provisions of the Labor Code, you most
forthwith comply with such provisions or this l craft atoll M dcemcd mwkcd.
CONSTRUCTION LENDING AGENCY
1 barony allirm Cu them is • cmwmedon lending agercy far the permrmanue of
the work for which Cb permit is issued (Sec. 5097. Civ. C.)
Londar. Name
Lenders Address
I redly that 1 haw read this application and mm ren the show information la
correct. I agree to comply with all city and county ordinances end Sum law relating to
building conmuctlon. and hereby and o lm mpruenutiw of this city to cnkr upon the
above-mentioned property for inspection Purposes,
(We) agree to save, indemnify and kap harmless the City of Cupertino against
liabilities, judgmenta. eau and expenses which may In any my acme against said City
in consequence of the Scanting of this Permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date /
S RR ULAMOOlNS.
Re -roofs
(//���C�-�A
F': "M i' I 04
si atart�pi�VCantrsemr D ata
HAZARDOUS MA DISCLOSURE
Type of Roof
Will Me applicant or (Marc building aaupant mom or handle huardaes material
as dcBned by de Cupertino Municipal Code. Chapter 9.12, and dm Health and Safety
Cade, Section 65551(.)7
All roofs shall be inspected prior to any roofing material being installed.
OYcr 4DNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
I brmdaus air comamlums u de0ued by the Bay Area Air Quality Manegcment
all new materials for Inspection.
tticM7
0 Yu *Nu
I have read Ce loasNuu mmedsic q.hernow.aderChmatc, 6.95 ofthe Cair.,
,•,
ni.Hmlth@SatetyCo .Satim25505,25377aru111574.1 "ifft W,Iding
Jm no a l y haw a mnan, Cm It b my responsibility m notifyoccupant of Me
Ire m uubcmetpn.0to anmaf.Cersin"major Y.
Signature of Applicant Date
c -z.1
Owner or authorized agent Data