05030157CITY OF CUPERTINO*
CONTRACTnR INky`O.�qRp�M�ATION `�,:
BUILDING DIVISION PERMIT
LL. ,.,.;FL,Td �.. .F .:'w.Z
BUILDING ADDRESS:
J. M. O'NEILL, INC
PERMIT NO.
05030157
OWNER'S NAME:
PERMrf ISSUE DATE
E:
NITARY OL NO.
A0.CHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
1 hereby affirm that l am licensed under provisions of Chap or 9 (commencing
withScotian 10(118 of Division Sof the eusinev Prufessimru Codc.andmylimenseis
mm�rm anaerc 1
REVISION--IN HOUSE USE ONLY
Liccnzc CI Lk. a
Dam canmmpr
NO NEW PERMIT ISSUED/ORIG. 404070055
ARCHITECTS DECLARATION
I undcrsunJ my plans shall banned v public records
REVISION--#04100177
Lkcnsed Pmfcssional
OWNER-BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Commmor's License Law for the
following moron. (Section 7031.5. Business and Professions Cade: Any city or county
which rcyuims a Purbit to consumer, a er, hnprom, mobuish, or repair any structure
Prim m its issuance. also requires the applicant forsuch Peoraft to file a signed sulement
Sq. Ft. Floor Area
Valuation
that W is licensed pursuant to Ne pmvisionsof the Conlncmrs License Law (Chapter 9
(commencing with Section 7") of Division 3 of Ne Business and Professions Code) or
Nat he u exempt therefrom and the bub for @e alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects dr, applicant o a civil Penalty of
not mare Nan fits hundred dollars (5500).
❑ 1, u owner of the pmpeny m my employcu with wages u their rule compcnution,
32633103.00 Required Inspections
will do the work, and the structure is not intended or offernd for sale (sec. 7064. Business
and Professions Cade: The Contractors License law does not apply to an owner or
property who bunds in improve daemon. and who doessuch work himsd for through his
ownemployces, provided that such improvements am not intended oronercd forsda, If.
however. the building or improvement is sold within one you or completion. the owner-
builder will have be, burden of proving that he did not Wild or improve for puryose of
sale.).
confessions with licensed ronlrubrs m
co L as owner of ct property, am Business i-
censwewum Li-
not (Sec. 7814, Business and Profusions Code:) The Cs
\\\S\\
human,
c u taw dose not apply loan owner of proper( who Wildspor improves daemon, and,
censees
who contracts for such projects with a contractor(s) licensed pursuant m IW Contractors
❑ 1 am exempt under Sec. B A P C for this mason
C
Owner Data
v
WORKER'S COMPENSATION DECLARATION
1 hereby alBrn under penalty of perjury ane of the following decleraions:
have and will maintain a Cenificam of Consent to self-insure for Worker's Compcn.
ton, ns provided for by Section 3700 of the labor Code. for Ne performance of the
work for which this permit is issued.
i?3ll have and will maintain Workcr's Compensation Insurance, ss required by Suction
3700 ofthe labor Cade. for the pederi mce of the work for which this petmit is issued.
My Winow'y, CoComypeasartii 0Immensml1RRJee1carrier and Policy numberab`n-
Camcr: aa�y'r Policy No.: T
'
CERTIFICATE OF EKEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
• (Thissection eeednm WcomplemJ tithe permit is forone hundred dollar (SIM)
less.)
I mnify that in the perfmmanee of Ne work for which this Permit u issued. l shell not
employ any Notion in any triumvir u a m become subject to NC Worked Compenestion
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Ccnirimue of Exemption, you should
become subject to the Workers Compensation provisions of the labor Code, you must
foMwith comply with such provisions or this remot shall be decreed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby thi that there is construction lending,Cagency Ins the performance of
which s
' the work fur which this permit is issued (Sec. 3097, Civ. C.)
Isndcr's Name
Lender's Address
1 minify that 1 have read this application and sum that the above information u
' corm. I agora to comply with all city and county ordinances and state laws relating to
building construction. and hereby authono, mpresenutives of this city to enter upon me
3 ahove-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless te hCity of Cupertino against
liabilities, judgments, casts and expenses which may in any way see= against said City
in consequence of the granting of this permit.
' APPLICANT UNDERSTAND Nip VL COMPLY WITH ALL NON-POINT
Issued by: Date
SOURCEREGU w D�
�I
Re-roofs
Signature of inno nuns Dalc
N ARDU MATERIALSDISCLOSURE
Type of Roof
Will dam applicant or fur building occupant store or handle huallous material
ra dented by the Cupertino Municipal Code. Chapter 9.12. and IM Health and Safety
code. Scdtie2ss32(,)7
❑ Yes AN.
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 Ne aPPlicamor fmure building Occupant use equipment or devices which
it haraNnus air conuminanls a definnd by IW Bay Area Air Quality Management
all new materials for inspection.
suict7
❑YesNu
I have reel the hevaMoos mammals mquiremenu under Chapmr 6.95 of the Cabot,
niaHdalthB:Safeycom.Sectiones .25533 and 534.1 unJcrsund davifda Wilding
Jots not currently mnank ybes ihility m notify ds occupant nr the
mgmmmcakx wh mat rata frCemficampf cap cy.
Signature of Applicant Date
10
ODow
All roof coverings to be Class "B" or better
owner orm a I
0