04100177CITY OF CUPERTINO -
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
J. M. OtNEILL, INC
PERMITN04100177
10275 N DE ANZA BLVD
OWNER'S NAME:
PERMIT ISSUE DATE
INTERO REAL ESTATE
5880 W. LAS POSITAS B
11/18/2004
NE:
SANITARY NO. CONTROL NO.
(925)225-1200
ARCHITECT/ENGINEER:
BUILDING PERMIT.
ER INFO "
PL
ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
p
mby AM that 1 am I used ruler pmvivons of Chapter 9 (rnmmeneing
with tet n]IXXB of Division 3m` and Processor Code.andmylicerueiS
in:i t<eandaf�_
xLiclp
REVISION--REPLACE ROTTEN BEAMS
License Clara l
Dam Contractor
NO NEW PERMIT ISSUED/ ORIG. #04070055
ARCHITECTS D6Put A ON
I
�I understand my plans shall be used as pull✓�(rnrds
Licensed Professional
OW NERBUIIDER DECLARATION
1 hereby affirm that I am exempt rem the Contractor's License Law for the
following saran. (Section 703 1.5, Business and Pmre.0 nns Code: Any city or county
which requires a permit to consumer, elmr improve. demolish or repair any Strucmrt
(ummcm
poor m its issuance. alum n to the the applicant roe such permit m . a Law
thamculi¢nwit pursuant to rl the Comsiness Licenselso (C
Sq. FL Floor Area
$+
Valuation 0
or Division Code)
ixemitn Section7")or Division] or NCeged Business and Professions Code) of
- - - - — -- - - -
mat he u exempt Ihem(mm and the, Ensu Ire tM alleged exemption. Any violation of
dou re, it
APN Number
Occupancy Type
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Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penalty of
not more man Bve hundred dollars ($50432633103.00
Dl,ssownerofthepropeny.ormyemployceswithwagesmdteirmlecmnpcmdan,
'
willdo thework, andmeawctum isnotintendedorolre fors le(Sec.]BU,Badness
Required Inspections
and Professions Code: The Contractor. License Law Ear oat apply m an owner of
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property who buildsorimproves macro, and whodoessuch work himselforthmugh his
own employees, provided mat such improvcmcnu me not intended oroRered forsale. If.
however, me building or improvement is Sold within one year ofcomplMon. the owner-'-
builder will have the burden of proving that he did nm build m improve for puepase of^—
sams.
,1, a. owner or One property am exclusively contracting wirelicensedmrs m licensed co nnu
Nm doe Pricer ($ec. 70:4. B.m. and Profeaskmi Code:) To, L'omfaemea Li.
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came Taw docs not apply to an owner or prepany who builds or improvr domen, and—
whocontractsforsuchprojectswithacontnctor(s) licensed to Oe, Contractors
pursuant
Kraw V
1e
❑ Itun Sec .B&s or this In.
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Oyner Dam
�' fj'f COMy NSA71 N�EILAARRATION
I herby eflirm under panalty of pepury o`netahc following derivations:
-
1 have and will maintain a Certificate of Consent to self-Insure for Worker's Cooper.
svion, ns provided fm by Section 37Mof the labor Code, for me pcefonnance of the
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wad for wM1ieh this permit is issued.
❑ I have and will maintain Workers Compensation Insurance, m required by Section
-
311 of me Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number arc:
C er. Policy.
CERTIFICATE OF E%EMPTION FR ORKERS'
COMPENSATION INSURANCE
(This Section need not be completed if the recruit is future hundred dollars ($100)
or Ices.)
1 CMJfy Lou in due performance, of the work for which this Permit is issued, l shall not
employ any person in any manner sn AS to become Schutt, to the WorkersCompensation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, aper making Nis Certificate of Exemption, you Should
become subject to the Worker's Compensation provisions of the Labor Code, you mus,
forthwith comply with such Provisions or oris Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I beshy affirm that inert is aconstructinn lending agcmy for the Performance of
me work for which this permit is issued (Sec. 3(1 Co. C.)
Untie'a Name,
GeAddress
I certify that 1 have read this applWmm AM sum that the above information is
correct. I agree to comply with all city and county o d inan2s and Sum laws slming to
Wilding eonsuuetion, and hereby mumn7a rep=mAtives of Nis city to cnmr upon one
strove-mentioned pmIMr y for impecuon purposes.
(We,) amen m cast. indemnity and keep hay tint against
liabilities sect'u in
which they in any way scare egainsssai0City
yae ro against
ccofun,emuandexpcnus
in sect cc of the mg u his 't.
PLICA UN RSTAN A W L COMPLY WITH ALIS NON POINT
Issued by: Date
S E UL .tt rl6 �C
Re-roofs
Type of Roof
T
gnswre ofApplicaHACZARDOUS MATERIALS DISCLOSURE ate
Will Ne applicant or fume building Occupant stow or handle havardous material
AS defined by dm Cupertino Municipal Code, Chapter 9.12 and use Health and Safety
code. omnzssJza)?
Ycs i .
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 mea applicant or future building Occupant use equipment or device. whim
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mit harardnus air contaminants u defined by Ne, Bay Arca Air Quality Management
.Ail Guilty
all new materials for inspection.
District?
❑Ycs AN.
1 have mad me hanNnus materials requimmems under Chapter 6.95 of the Carter'
On,dcty Calc. Seem 25N)5.25533 And 21534. 1 underamnd mat if the building
It its �04
Mug( Curr try have a nl"maTil m nMly the pan
QMYOmspppsihit,,,
req n, wh' her e,pri ssu cc\eaTT''lllhiicceddcamaro €r.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
owner at aumori cd agent '� Date