03090115CITY OF CUPER'rINO
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BUILDING DIVISION PERMIT9
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INFORMATION >,,_6xro�.
4CONTRACTOR
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BUILDINGADDRESS:
J. M. O'NEILLr INC
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OWNER'S NAME:
5880 W. LAS POSITAS BLV, {f
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)NE:
(925)225-1200
SANITARY NO. CONTROL N0.
ARCHITECTPUNGINEER:
BUILDING PERMIT INFO
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LICENSEDCONTRACTOR'SDECLARATION
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Job Description
1 hereby that 1 am licensed under provisions Chapter 9lcoylicar ng
that I under
p
ur
r).d Division Sof IAc Ousinca and Profcminnx Codc, end mylicense is
MirSectionand
in full force and effect.
affect.
License elms
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Date untroctor
Can,
ARCHITECPS DECLARATION
I understand my Ilam shall he vud as ohlic records
SEP
SE p /$2003
Licensed Pmfcuionei
OWNER-BUILDER DECLARATION
1 botchy .(Sero Law for the
that 11. exempt from de Cssiums Any
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(Section ID3L5, Business and o :
maso o c
ions Code: Any city at ramay
following re rens
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a d
alter, improve, demolish, or repair any swcmre
improve.
which requires a permit re cowl
Lim
poor to its issuance, pursuant to the the applicant for such permit Glco signed Chumem
that in is licensed Parsaammthe provisions of me comracmrs Lianxe law (cn.Pmr9
Sq. Ft. Floor Area
Valuation .
of Division3 of Gale)tar
(commencingwithhertiro
allegedAnynvi
Natio is exempt therefrom and the hexa for the alleged exemption. Any
and
lty of
32633103,00
Secnot.. 7031.5 any l Pen
rota pont¢ subjects the eCPlieam to uiril penalty of
- -
Number
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Occupancy
five red d.t
not doe Iran Gw hundred donate ($SW).
.APN
-Type
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❑ I, u owner of the property, or my employees with wages as their ale compensation,
will do Ne work, and me sou tum is not intended or offend for sale (Sec. 7064, Business
.it Pmfeuion, Cade: The Contractors Liana taw does nm apply man at, of
Required Inspections
propeny who builds or marrows doemun, and who does such work himselfor through his
304 - ROUGH ELECTRICAL
own employees, provided that such improvements are not inmoded or offered formic. If,
.-
however, me building or improvement is sold within one year of completion, me owner
builder will have the burden or proving that he did not Wild or improve for purpose of
sale.).
❑ 1, as owner of the pmpeny, am exclusively contracting with licensed contractors to
- -- —
construct the project (sec. 7844, Business and Professions Code:)The Contractor's U.
come Law does not apply to an owner of property who Wilds or improves demon, and ,
who contracts fur such projects with a contractor(s) licensed pursuant to the Connor's
uwenu Law,
_
❑ am x pt d , B h P C mtthi mon
a /IQ
ner 0
RKER' PENSATION DELLA ION
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IMreby mmunder pemlty of perjury one of efollowing declarations:
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I have and will maintain a Candies¢ of Consent to sel6insum for Worker's Camper
.tion, u provided (or by Section 3700 of On LaWr Code, fm the performance of the
work for which this Permit is issued.
❑ I hats and will maintain Workers Compensation Insurance, m recruited by Section
3700 of the labor Code, for the performance of the work for which this Permit is issued.
My Workers Compensation Insurance carrier and Policy number arc:
Carrier: Policy No.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
mils action need nut W complemd if lW Permit Is for one hundred dollar (Slap)
it, lms.)
1 certify that in the p ffionance of the work for which this permit is iuucd.I shell not
-
employ any Person in any manner sat as In become subject m the Workers' Compensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, alter making this Cemicate of Exemption, you should
become subject Io the Worker's Compensation previsions of the Ichor Code, you most
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there its construction lending agency I'nr the perrurmmce or
the work fur which this permit is issued (Sec. 3097, Civ. C.1
fender's Name
Lenders Address
1 mnify, that 1 have read this application aM sues that the above information is
correct. I agree to comply with all city .d county ordinances and state laws relating to
building construction, and hereby authorize upresenmiva of this city to enter upon the
above-mentioned property rot inspection purposes.
(We-) ague to saw. indemnify and keep harmless w City of Cupertino against
liabmact,utnee. judgments, costs and cataracts which they in any way eccmc against said City
of
of griming of this permit.
A
APPLICANT
APPLICANT R NOS AND WILL COMPLY PTH AL O POINT
Issued by: Date
SOURCER /
Re -roofs
Type of Roof
/ I/O_
jjifliawoeerXprifivcanuMtor Data
HAZARDOUS MATERIALS DISILOSJIE
Will she applicant or future building occupant store or handle hazardous material
u defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Co de, Section 25532(.)? -
Yes Nu
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or Lure building occupant use equipment or devices which
it hammms aircommminanu u on by de Bay Arca Air Quality Management
all new materials for inspection.
nuict7
❑Yes Nu
I have read the haeNaus mmerialerequirements under CNpmr6.95 oris carrier.
ria Heal ode, Secdo. 255)5.25533 and 25534.1 undersand do if the Lai lding
doea nal curs y awe ant. that it is my rmponsihility m arefy, sreup.t of the
requirements hi melpdorwissuanexaraCeNGc o(excep.ry.
Signature ofApplieant Date
All roof coverings to be Class "B” or better
O ner or .mho' agent
D„e
*cin or
MkTINO
CITY OF CUPERTINO
TEMP POWER
PERMIT APPLICATION FORM
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APN #
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Date: d
Building Address: 0 2
Elect. Permit Issuance
ELECTRICAL
1
/
BUILDING
Owner's Name:
Phone #:
Contractor:
Phone:
License #:
4� 2-!� -22---r2-C2c3
Contact:
Phone:
Cupertino Business License #:
T Com,
2 - 2zs—I2-00
Building P rmit Info:
Elect ❑
Job Description:
Residential ❑ Co
mercial ❑
Cost of Project:
Qty. if -,
Annlirq le 1 Fee, M
Fee Descrintion
Fee Grouu
$TEMP
Temporary Power
ELECTRICAL
EPERMITFEE
Elect. Permit Issuance
ELECTRICAL
BUSLIC
Business License
BUILDING
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