04120048LOFQF
ea,
2
Z�u
in
SOC
a
t -z>
R
02
z
CITY OF CUPERTINO
PERMIT
"'".'+ F �� x•',
CO1�ITRACTOR INFQRMATION.
.... -.
- —
BUILDING DIVISION
BUILDINGADDRESS:
J. M. O'NEILL, INC
PERMITN004120048
10725 N DE ANZA BLVD
EWS NAME:
1
PERMITI SUEDATE
BEIM & JAMES PROPERTIES III
5880 W. LAS POSIT
ONE:
SANITARY NO. CONTROL NO.
(925)225-1200
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO J
'
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
I hereby affirm Nat I am licensed under providons of Chapter 9 (commencing
I3 ..
with Section 7") of Division 3 of On Business and Profession Cade, and my license is
infail lambent! eftea
REVISION --IN HOUSE USE ONLY
License ClassLk. N
NO NEW PERMIT ISSUED/ ORIG. ${04-100010---
Dam Contraelor
ARCHITECTSDECLARATION
1 mccrstand an, plans shall M used as public mcmds
Licensed professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Taw for the
-
following reason. (Section 113 L5. Business and Professions Code: Any city as county
which requires a permit to component, alter, improve. dcmalish, lir repair any structure
prior in its issuance. also requires the applicant for such permit to file a signed statement
that he is licensed pursuant to the provisions of the Contractor's License Law (Copper 9
Sq..FL, Floor Area
-'
Valuation$35
(commencing with Section 1000) of Division 3 of the Business and Proremans Code) or
Wt he is exempt therefrom anal the basis for the alleged exemption. My violation of
'
APN Number
Occupancy Type
Section 1031.5 by any applicant for a permit subjecm the applicant m+ civil penalty of
not mom than fire hundred della. (1500).
32610065.00
0 1, a owner of dm property, ar my employers with wages as their sole compevation,
'--Required Inspections
- - fl p
will do theworkand ma.momme is not intended or offered for sam(Sa. 1044, Business
and Professions Code: The Contractor's License Law dura not apply to an owner of
Property who builds or impfoves thereon, and who does+uch work himsdfor through his�-
own employees, provided that such impmsemenm am mrimmaeed or offered formle. If.
however, the building or improvement is mid within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
.. -
.in.).
❑ I, ower of the property, exclusively confessions with uontrano.
U. construct the project )Sec. 1044. Business and Professions Cade) Tne ContrssroYs fu�
u . B sine :) ran C
_
amu law cuts not apply to an owner of property who improve
ofrac
whocontractsace for such pmjecm with a contrssmr(q licensed pursmm m the Contrumn
sed p m Contractors
License law.
❑Lem uempt under Sea ,Bb.PCfor mi, mason
cr Date
_
-
WORKER'S COMPENSATION DECLARATION -
Iherebyaffmr under penalty of perjury one of tk fallowing clan ations:
I have and will mainuina Cenifcam of Canunuoxlf-insure far her'a Compcm
salum. as pnavicied for by Section 3100 of the labor Code, for the do.. of the
work for which this permit is issued. /
❑ 1 ban and will maintain Workcr's Compensation Insurance. as uired byiSocuon
3100 of be labor Code. for the performance of the work for which is permi isissued
-
My W.Ace. Compensation Inm.oce eaniu and Polity number
Carrie,. Policy No.:
CERTIFICATE OF FXEMPTON FROM WORKERS'
' COMPENSATION INSURANCE
(This section coed not W comported tribe Permit forma, nu red Ilars($ )
or less.)
1 certify that in the pmformanee of the work for which this p,�nit ice' ucd. I shal at
employanyperson in any mannerm a to become mbjecuot Worke 'Comp, tion
Laws of California. Data
Applicant
- -
NOTICE TO APPLICANT: If, after making this CcNf am of Exemption, you should
become subject to the Workerp Campcnmtion provis' m of the labor Code, you must
' foMwith comply with such provisions or this permit'ahail W deemed invoked.
CONSTRUCTION LENDING AGENCY
I herebyich chi Nat them is a construction lending agency for the Performance of
' the work for which the permit is issued (See J(N1. CO. C.)Lerid
-
sNae
Lemiclm
tender's Address
�^
/J .
j I certify Nat I have mad this application and sum roar the .hove information is
' ca oat. I agree ro comply with all city and county ordinances and sate laws relating to
Wilding construction. and hereby 0umorie, miumenutives of this city to enter upon rhe
1 above-mentioned property for inspection purposes.
(We) acme to save, indemnify and lou p hanmloss the City of Cupertino against
liabilities,)udgmema. 0033 and cxpenYa which may in any way accme against mid City
in consequence of the granting of this permit.
' APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Dat -
SOURCE REGULATIONS.
GO/
Re -roofs
Type of Roof
Signature of ApplicanUConDam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future bending occupant store of hooch material
Health
efined by the Cupertino Municipal Cage. Chapter 9.13. and the Health and Safety
c. Section 23533(x)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes ❑No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =upant em equipment or devices which
t hazardous air contaminants u dcrined by dte Bay Area Air Quality Management
all new materials for inspection.
rict?
Imquircownts;
❑Yes ON.
I have mad the haoolo s materials mquinemems under Chapter 6.95 of the Califon
Health k Safety Code, Scctiom 35505,35537 and 35534.1 understand that ifthe building
s not currently hast a ¢mol Nat it is my MoOnsihility, m m of y de occupant of the
which mart he met prior an issuance of. cenincate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner
or aethorird agent Dam