00050175 ,
CITY OF CUPERTINO
BUILDING DIVISION PERMITC1 E
CONTRACTOR INQRMATIU :
BUILDING ADDRESS: k MIT C.
JEFFREY O 'NEILL CONSTRUCTIOT
OWNM Me FGRG2 BR 4125 GLADYS AVE PERMIT O
E: SANITARY NO. CONTROL NO.
(831) 479-1144
ARCH(fEC AINGMEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MUCH
loo LICENSED CONTRACTORS DECLARATION O O O
1 burcby affirm that I am licensed under prov Won&of Chapter 9(commencing Job Description
with Section 7(Ak))OfDIAsn.Saab Buainem,nd Professions Code,and my he...is
in full forte and effect.
is License Class Ue.« TENANT IMPROVEMENT TYPE III—N/ B OCCUPANCY
Dau Contractor
1I� ARCHITECTS DECLARATION
IuMeraund my plum.ahall busedas public record,
/^ 5
ED
_
s Licensed Professional
OWNER-BUILDER DECLARATION JUL 3 1 OO
5i 1 hereby aIOron that I em exempt from Ne COnlrscsors License Law for the '
$�O, following resume.(Section 70315.Business and Professions Cade:Any city or county
which repdres•permit to construct.alar,sorrow,demolish,or¢pair any structure MR ago
ZS° prior to its Issuance,also requires the applicant for such permit to file a signed statement moms
that be is licensed pursuant to the previslmu of the COntrmtori Uccnse Law(chapter 9 Sq.Ft.Floor $1608 11:9hon
$ (commencing with Section 7")of Division 3 of live u
Busineand Prohssions Code)ser
That he Is exmnpt therefrom and the bash for the Alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit ubjects the applicant to a civil Nutty of
not mare than Rw hundred dollars(SSW), 3 AVO 0 Occupancy Type
❑1,as owner of the property,or my employees whir wages As Ombsole compensation,
will do the work,and thuwctum ltnoUntendedor Offered fonele(Sec.70,14.Business 101 - FOUNDA
and ROfestiont Code:The CUatM'tora License law does rot apply m an owner of WW011id Inspections
property,who Wild m improve lhereem,ad whodaeuuch wmkhimsctfor through his 102 — PIERS
own employees,provided that such Improvements Am not Intended oroaered Mrssu.If, lO3 — UFER
howewr.the building or improwment h sold within one yeu of completion.lhe weer.
builder will luso the burden of proving that he did not build or improve for purpose of 104 REBAR
talc.).
01.as Owner of the property,am exclusively contracting with liewed cones crato 105 — ANCHOR BOLTS
construct the pmject(Sec.7(ua,Business and Professions Cade0 The Conmcmrs U. 106 — SEWER & WATER
mnse taw does not apply to in owner at property who Wilde orlmprows thereon,and 2O2 — UNDERFLOOR PLUMBING
who contracts for such prome projects with a convector(&)licensed pursuant to Conuutm's
.aw.
0'.. 203 - UNDERFLOOR MECHANICAL
slam esempt underSa ,B&PCfm thts recon
Date 204 — UNDERFLOOR FRAME
0. WORKERS COMPENSATIONDECLARTION 205 - UNDERFLOOR INSULATION
I hereby affirm under penalty of perjury one of the following declarations: 301 — ROUGH PLUMBING
en,nd will maintain a Certificate of Consent to self-feu.for Worker's C.N. 302 - TUB & OR SHOWER
assume,As provided for by Section 37W of the labor Code.for me perfoon..of the 303 - ROUGH MECHANICAL
work for which this permit is iumd.
❑I how,and will maintain workers Compensation Inrunnce,u required by Section 304 - ROUGH ELECTRICAL
37W of the labor code,for me performance of the work for which this permit is issmd. 305 — FRAME
My Workers Compensation Intercarrier d Polity number art:
Carrier. Policy No.: 306 - HOLDOWNS
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 — SHEETROCK
Ac leu.(TMs senior need not W completed if the Permit Is for one hundred dollars($100) 309 - EXTERIOR LATH
1 cenify that In the performance of the work for which this Permit is issued,)shall not - 310 — INTERIOR LATH -- -
employAnyperroninanymannersoossebecomesubjectto the Workers'Compansstiun 311 — SCRATCH COAT
Law&of California.Dam
Applimm 313 - ROOF NAIL
NOTICE TO APPLICANT:IL after making this Cenificare of Exemption,you thouM 501 - FINAL ELECTRICAL ENERGY
become subject to the worker's Comrcmation provisions or me Labor Codc you most
.,O forthwith comply with such pmdtinm or this permit shall N deemed mwked. 502 — FINAL PLUMBING ENERGY
CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
(hemhy ellifm that dereiu construction lending agency for ti.Pcrformsrcc of 504 — FINAL BUILDING ENERGY
x ti the wurI for which this permit is t a co (Section le
32Q Lenders Name 505 - FINAL ELECTRICAL
?z Lender'AAdd.ss 506 - GAS TEST
J Q I certify that 1 haw road this application and suss that the show Information is
yFcorrect.I agree in empty with all city and county ordinances And MM laws Missing to 507 - FINAL PLUMBING
Q V building construction,and hemby audmflm representatives of this city to cram upon tiro FII,] MEC CAL
abm
ow- entiuned property for Inspection purPMEL
H y (We)agme on sow,indemnify and keep harmless the City of Cupertino against 09 F I .
.w N Iiabllities,judgments,costs and expenses whichmayinanywayaccmcagelnstaidChy' S NG
J7 in eoraqucnce ofthe gnnting ofthh Permit.
r7 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by:5 C WORKS Date
SOURCE REGULATIONS.
Re-roofs 516 NAL BUILDING
Sigmas.of ApplicaHAZA DO DAse -
HATorform MATERIALS dseemoSURE Type of Roof
Will We applicant m,(mum Wilding e,Chml atom orhandlet h eallom motorial -
as de0m0 by the CulaeninO Municipal Code,Chapter 9.12,and the Nalco and Safety
Code.ScNen:ss32(e)T
❑Yc& ONO All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or rule.building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
hamMum Air conurnimis a&deMcd by me Bay AM&Air Quality Management all new materials for inspection.
"let?
❑Yes 0 N
1 bevc mW the h urdous maurlalsmquimmenu underCMpmr6.95 of the C lifor-
nixHeslth&SafctyCW.Sw9=25505,25533 md2553s.1 uMmsmnd thmirw building
dors rot currently haw a"Art,mal It is my responsibility to only the emupenl of me
requirements which mot be mel prior to issuance of a Cenlftea a of Occupancy.
Signature of Applicant Date
Owner at aulhorind agent Date I All roof coverings to be Class"Bat Or better
iv
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