04070004 C[TY OF CUPERTINO
BUILDING DIVISION pERMI'I' 'caCONT,R'AC�TL}I2INFU-X21YIA�LOO N `«
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eu11DING ADDRESS: NIELSEN/HIRE CORP PERMITN904070004
20650 STEVENS
OWNER'S NAM E: PERMIT ISSUE DATE
VANILLA SHELL 1601 GALVEZ AVR n04
E; SANITARY N0. CONTROL NO.
415 643-8930
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EI,ELT PLUMB MECH
oo LICENSED CONTRACTOR'S DECLARATION Job Description
1 hcrcby afnrm that I em licensed under pmviai ns of Chapter 9(commencing g. P
IN5a�Hon 7IXIU)of Diviaion7of the Buainesaendadons Code.and mylieanseis s ��
A� aldlhm nderrea. TI--DEM ADD 2 RESTRMS & CEILING
��? Dam a Cunnaclm O i? r
Pq. ARCHITECTS OEC ^�T/`�'t_y��
1 understand my plans Mall M used As public records WK2005
}z
7d iv Ltd J
g G Licensed Professional
OWNER-BUILDER m DECLARATION if'Y, p p ria
I 1 hereby Alnrm that I am excmpl from the RATION lawns=law for the slflt4Gr1O V IrIJ.(t t0iw\\\`'fNl
p 0 following mason.(Sutter,70313.Beat..and Prefessiens Code:Any city ar county
$8! which requires a Permit to construct.alter,improve,demolish,or repair any structure
�y prior in is issuance.caw require,the applicant for such Permit to file a signed mmmem
< that he is licensed puissant mthe Ppa,ummiofHmCimuscmhUccowLaw(Chap=9 Sq.Ft.Floor Area Va nation
9 (commenringwith Section 7000)of Mirshn 3 of the Business and Poefesainns Codi ur
..
that he is exempt Bamfrom and the basis far the alleged exemption.My violation of
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penalty of e10 0 Occupancy Type
not more than Ilse hundred dollars($500).
❑L as awner of the propeny,m my employees with wegessaxii intik tomPenaden.
willdotheworkmdthestroctumtsmotintendedmoffercdfmsale(Sec.70N,Busimu Required Inspections
and Professions Cade:The Conuacmrl Use=Law taus ret apply m an owner of q P
progenywho builds orimpraves disease.and whodoesshaltworkhim ie ror Untaught his
awn employees,provided Iheuuch improvements Are not Intended or offered fm We.If,
however.the building or baprowment is mid within aro you of completion,the owm r.
builder will have the burden of proving that he did not build or improve fm purpose of
sale.).
❑1,As owner of the propeny.am exeluawly contracting with licensed cenummra to
mnnmct Ne project(See.7040,Business and Profrssions Code:)The Connector's LI-
cemse law does oat apply in an Ammar of property who Hilda or tmprovea daemon.red,
who announce,for such pmjecu with a comncmr(s)licensed pursuant in the Comrmtor's
License Law.
❑I Am exempt under Sao. .B&P C for this raison
Owner DataAlk '
WORKERS COMPENSATION DECLARATION
1 hemby a1Bmt under penalty of perjury aha of the fallowing declarations:
haw And will in ins Camili.amof Cansemm self-InsureforWorker'sCompen-
Han,As pmsIdM far by Suction 3700.f the labor Code.for Her perfernmee of the
work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insuo n e,As required by Sccdnn
3700 of the lobar Code.for Hm perfarmahaeof the work forwach this permit is issued.
My Worker's nnmEl�e.n tion Inmrsnce carrier and Polity num em:
CerP S�a�e uv.Ol Poll Na.: 1 3 . '
CERTIFICATE OF EKEMFrV FROM WO KERS'
COMPENSATION INSURANCE
mils d.hand ambecompleud lith ro.I,is two.himdrcdddlars(SIM)
in I..)
1 certify Net in Ne performance of the work for which this permit is issued,I Mill not
employ any person in my mamrerm As m became subject to the Worked Compensidon
Laws of Celifomia.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you Mould
become subject to the Wo ',Compensation provisions of the LAW Cade,you mail
wJ Q forthwith comply with men previsions or this permit Mall he deemed rcwked.
,za ti CONSTRUCTION LENDING AGENCY
(-. 1 hereby Man that there iso construction lending agency for dm performance of
ai it Ne work for which this Permit Is issued(Sec.71ya.Civ.CJ
0�.Q Land
ets
Z)z Lend
er'sAddress
V 0 1 ceniry that 1 haw rad this application and sum that dm show information is
Iycermet.l agree to comply with all city and county wdiauntss and state laws ni m
OkS."J Wilding construction,and hereby school represemadves of this city to enter upon the
` ahove-mentiahad property for impecdon purposes.
Ff'i 0. (We)agree to sarc,indemnify and Inept harmless the City of Captain.against
Cr, lobilides,judgments.emts andexpeasef which may In Anyway accm=against said City
in
V^ APPLICANTAUNDERSTANDS of AaND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SO R ULATIONS.
'�A+a 4 Re-roofs
D"alature ofApplicanRData
I IrD A'(/SMALS DISCLOSURE Type of Roof
Will the applicant or future building occupier tore m handle barardous material
As deM=d by the Capsulate Municipal Cade,Chapter 9.12.And the Health and Safety
Cade,Section 255324)? All roofs shall be inspected prior to any roofing material being installed.Pres No
Will the applicant or future building excellent use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
It havaidnm air conuminants u Harmed by the Bay Area Air Quality Management all new materials for inspection.
inrin?
[3 Yes ION.
I have mW the hnardcws mammals rcquimments under Chapter 6.95 of IN Calilor.
nia lieal"Safety,Code,Seams 25505,25373 and 25534.1 understand thin it the building
docs not c nHr hew i tanAnk that It ta my respons iniity m andf the axcupanl of the
rcquimm ren uslhmdpnar tencenificate r eapm=r Signature ofApplicant Date
owners mmeHuedeg=fit �m All roof coverings to be Class"B"or better