04100010U
yITY OF CUPERTINO
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CONTRACTOR INF®RMA, 5N ", -R
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BUILDING DIVISION PERM-
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BUIL DING ADDRESS:
J. M. O'NEILL, INC
PERMIT NU.
04100010
IER'S NAME:
PERMITISSUEDATE
E
5 NITARY O. C N OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
DLDG ELECT PLUMB MECH
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LICENSEDCONTRACTOR'SDECLARATION
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I affirm that 1 am licensed under provisions of Chapter 9 (commencing
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-[9{tIQ❑ as
with SCIdereb, Uf Division 3 Of Busircssand ndmY daerux ill
ion 7
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ED
in fwl to. and effect.
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TI--LOBBY/l, 2, 3 FL. u
License Class Llc.a
Due Contractor
ARCHITECPS DECLARATION
1 shall he used as records
_... FEB 2005. _ ..._ .. .-
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understand my plans public
Licensed Professional
OWNER -BUILDER DECLARATION
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I hereby affirm I oro exempt tae Conuaewfs
Anycem. law for she
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srum
ium Code: Any city m roomy
reason. mi IImaclo Bminms and :
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Which re Perron t u, alter, ire n, de care any tucatm
which n:yus
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xiir
statement
hpermit, t
u n e. also rdnsput for such
rioreais,issuance,almarequites put applicant for suchpermitm Gens Law
(comm law
Sq. Ft. Floor Area
Va uauon
is licensed pursuant tothe of Division! theeB memr'snd Prom (Chod¢r9
Scmion](and of of a and Code) of
(commencingaisexempt
al ed exe on. Any
that he u exemps shcmfmm and the bazis for drc alleged exemption. Any vinlmian of
basis for
32^6`I40[10.0 (;1700
Occupancy Type
Section 1031.5 by any applicant for a permit subjects He applicant m a civil penally of
not more than Ove hundred dollars ($500).
I.asownerof pro withwagesas Heirsole compensation,
Required Inspections
andstructure is intended or (Sec. 7044. Business
will do He work and
a. d ..I L ram
tar Lt. taw does nos apply lf an awns of
and Code: The Contractors
e:
and who doasuch work himselfor his
property wmo builds or and
property builds
edthrough
ed that suHereon,
buiprovided for safe. If.
suchimprovements arenot ear
own emt,
due within One Of ter.0ered
bow eq Heaveting pr Of cprove on.fm thrpose
build Of
builder will have He burden of proving that he did not build or improve fur purpose of
ebrimpmvcmemishathe
.is
roperty, am exclusively contracting with licensed contractors in
L as owne;hy
caazwe the (Sec. Business and Profusions Code:) The Concracwr's U
tens, Law docanply to an owner, of propcny who Wilds Or improwe theater. and .
who contractsfor projects with a con ractor(s) licensed pursuant He Contractors
Lice ss Law.
lam exemSe B h P C for His reazon
Date 1d"
C COMPENSATION DECLAR NIhem
under penalty of perjury one of thea owing decimations:
ban andntain a Certificate of Consenuo self-bouat for Worket'a Compcn-
pror by Section 3100 of He Labor Code, for He performance of the
worku
for which Hier permit is issued.
0 1 have and will maintain Workers Compensation Insurance, as required by Section
3100 of the labor Code, for the performance of the work for which His permit is issued.
'
My Worker's Compensation Insurance carrier unit Policy number am:
_
Cartier. Policy No.:
CERTIFICATE OF EKEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(Tris setim, need not becompleled if ere permit is (moor Hundred dollars (SIM)
or Ices.)
1 comfy that in the perf immnec Of the work for which this permit is issued, I shall not
employ any Person in any manner sr u Or become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject ba He Worker's Compensation provisions of He Liber Code. you must
Z forthwith comply with such provisions or this Permit shall W deemed oinked.
0
y CONSTRUCTION LENDING AGENCY
I hereby affirm Hat there is a construction lending agency for the performance of
> thc work fur which this pram it is issued (Sec. 3091, Civ. C.)
fenders Name
z Lender's AdHcss
C) I certify that 1 hast read this application and scale that the show information is
.
correct 1 agree to comply with all city and county ordinances and sure laws relating to
building construction. and hereby authorise represenutivu of His city to curer upon to
cal above-mentioned property for inspection purposes.
6. (We) agree in save, indemnify and keep harmless the City of Cupertino against
liabilities,judgments, costs and expenses which may in any way nemc against said City
Z in consequence Of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINf
Issued by: Date
SO EGU ION O —/"Q
Re -roofs -
Type Of Roof
of A aon or
l ZARDOUS MATERIALS DISCLOSURE
Will applicam or fomrt building occupant a,.. car handle hazardous mamrial
On the Cupertino Municipal Code Chapter 9.11, and she Health Lend Safety
a de. section 1553$a)7
All roofs shall be inspected prior to an roofing material being Installed.
P P Y P g
E] Yes AN.
If a roof is installed without first obtaining an inspection, I agree to remove
Will He applicant or future building Occupant use equipment or devices which
it li vardous air contaminants az defined by the Bay Area Air Quality Management
all new materials for inspection.
isvlet,
OYcs AN.
I have read thc hanNnus narcosis requlmmcnu under Cba1w, 6.95 of He Califon-
ni.Health&Safety Code, Sections 15505.15533 and 15534.1 understand calf the Wilding
does nody an a tenant Har it u my respondimility to nobly the occuPam of the
rcy cm, themfoccmnmmc.lum ey.
Signature Of Applicant '' Date
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roof coverings to be Class "B" or better
Onrr.aa.m t Date