05030225 CITY OF CUPERTINO /� �*ymr.�g+w+g��sa♦,�*�.e
BUILDING DIVISION PERMIT kyoi\'Lll['14 (IRINFUyiMATIUNN
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMITN005030325
OWNER'S NAME: PERMIT ISSUE DATE
IlkTOWN CENTER ARROCTATPq S245 PACIFIC CONCOURSE DRTIE 08/29/2005
E: SANITARY NO. CONTROL NO.
510) 385-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
Loo LICENSED CONTRACTORS DECLARATION Job Description
Y I Mmby affirm Nu 1 am licensed under pmW
vons of Chapter 9(commencing
< with Scetion70110)of Divlslon 3 often Buoneu and Profcssluns Code,and my license is
infaBmmeandafrecL NEW CONDOMINIUM
01 LD:. ley Lk.g G/�U fid
Wig- oak Canlraamr 1349 SQ. FT. LIVING
ARCHf1ECrS DECLA1i1`D N�
I dammed my puna Audi be good As public necoNs
�n
Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hammy alarm that I am exempt from the Contractors License Law for the
i O O fallowing moon.(Section 7031.5,Businesa and Proussiuns Cade:Any city or aunty
$ which requires a permit to construct,eller.Improve,demaluh,or repair any Necture
Hsi poor to its issuance.also requires the applicant for such permit to file asigned statement '•a
ggg <
that he is licensed reactant m the provisions of the Contractorsmas LiLaw(Charter9 Sq.Ft.Floor Area Va &FD
6160
(commencing with Section 7")of Division 3 of the Business and Pmfations Code)or
that he t$exempt thomfrwn and Be,but$for the alleged exemption.My violation of
Section 7031.5 by any applicant for a permit subjects she applicant to a civil penalty of APN Number Occupancy Type
ret ream than five hundred dollar,(M). 36940002 . 00
❑L u hwmrk.tin pmpmty,or is intended
W wapc u Nem sole e0mpewonia
will dodrwork and tirmumwet$nm,Licari maQered fmaak(Sec.70 aa.Begonia
And myv,1 ou Cade:The Conuamors Liwho LawDes dao oak apply lf rt Durr is Required Inspections
properlyi builds orimpmwtchim rowawho doeaech Bort acoffe ed Waugh his
own emplayw,provided Nat such improwmcnts are not Intended moRmed for ole 1L
however,W building or improvement is sold within one year of completion,the owmr
builder w1i1 have the burden of proving that he tette not build m improve for purpose of
ole.).
❑1,as owner of the pmpeny,am exclusively contracting with Iittneed contractors to
consuum the project(Sec.7014,Business and Professions Code:)The Contractors Li.
came Law does not apply 0 an owner of property who builds or improws thereon.and,
who comma for such pmjems with aeomamor(s)licensed pursuant to Nc Contrectora
License Law.
❑I am exempt under Sec. .B 4 P C for this maxon
Owner Dam
WORKERS COMPENSATION DECLARATION
I hemby aRnm eager pemlly of perjury AN of W following geclartiotts
❑1 haw and will maintain a Canifaata of Consemm self-imam fm WmtefsCompen-
sssion.as provided fm by Section 3700 of the Isbm Code,fm W perfar nmec of do,
work for which this permit is iomd.
❑1 have and will maintain Workers Compemation Insurance.As required by Section
37W of the Labor Code.far W performance of the work for which this permit is bound.
My Worker.Compensation Insurance c�artAier and Policy number am:
Can)cr:L�'J�/LN 11`ke:f✓nPollcy Na.: it e_35 /030
TIFI�F170N FROM WORKERS'
COMPENSATION INSURANCE
This section need notnecamputad lithe ptwit is from hundred dollarepl I00)
or less.)
I certify that in the performance of the work fm which this permit is lured,I Mail not
employ any person in any maamr an As to become subject to tie Workers'Compensation
Lawes of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,cher matlng this Ceninak of Exemption,you should
became subjW W the Workers Compensation provisions of the Lame Cade,you must
,J O forthwith comply with each provision or this permit shall be decreed muted.
z CONSTRUCTION LENDING AGENCY
[•n I hereby affirm Nat Nam is c0nsumtinn[ending agency for the performance of
tYt 7 the work for which this permit is issued(Sm.3097,Civ,C.)
W Q Lender's Name ,
r7 zLender's Md
U 0 1 cenl(y that I have read this application and ata¢Nu the above infoonniun is
W U cormm l ague to comply with all city and county Ordinances nd sok law relating to
0 buildingconstruction,and hemby authodne represemadws of this city to enter upon IN
W ahow.raAmmmi Pmpcny for Inspection Purposes
(we)agree to saw.Indemnify and trop hann[eat the City of Cupertino against
ccj liabilities.judgmenu,cats and expenses which may In sty way amm¢against said City
UZ in consequence of the g.mq,of thus resit.
APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUI.a ONS.
/ 414-r- Re-roofs
Sign of Applicona Contractor an,
HAZARDOUS AATERIALS DISCLOSURE Type of Roof
Will W applicant ser Nmro building Dceupametota mhenmc husrdous materiel
u denmd by W CupeNno Municipal Code,Chapter 9.12,and the Hcalth and Safety
Cn[e,Section 25532(.)7 All roofs shall be inspected prior to any roofing material being installed.
Q Yes
Will Ore applicant or future building occupant on equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air ammninants u defined by the Bay Area Air Quality Management all new materials for inspection.
Di ricD / �
C]Yes 0415
I hes tad the huardrats materials requirements under Chapter 6.95 of the Califon
nu FlcaINBSJmyCoge,Sectimts 25505. 577 ua12533/.l undcntand Nuiftlr Wilding
does wt currently hew s tanank Na' my maponslhlllty to notify tin aceupant of W
mquimments which mug mm p' issutrta afa Ccnificaw of Gee: racy Signature of Applicant Date
Owmr authooaadAgent �� All roof coverings to be Class"B" or better �,.