05030242 CITY OF CUPERTINO
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BUILDING DIVISION PERMIT CUNTRATQI.t YNFURMA' Ots;
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO.05030242
R'S NAME: PERMIT ISSUE DATE
SIVLER
PHONE: SANITARY NO. CONTROL NO.
510) 385-0121
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDGELECT PLUMB MECH
0 I 0
LICENSED CONTRACTOR'S DECLARATION Job Description
g.� 1 hcrcby affirm that 1 am licensed under provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business ale Professions Code.and my license is
n in full fame and affect. NEW CONDOMINIUM
Dem Gon
2'�z Lleensa Cl LessYN 0NEy36L '743 SQ. FT. LIVING SPACE
0 ARCHITEDECr W QCTS DECLARATION
5a 1 understand my plans shell be used as public records
p v
s uO Licensed Professional
ay
OWNER-BUILDERexemptDE DECLARATION
ZOO hereby.('firm on 1 1. exempt from N,Convenors License taw for the
ZOO following tins a (writ t 71131.5,Business and tie.de unc Crede:My em or county
$ which requires•permit re enmaWel.alms improve,h permish,or e a sig any structure
_
prior mits iensedpalw requires the applicant far such permitm vie esignM summem "009
flNelheislieensadpumuanttothepmvimoluoftheContranweiLicenseLaw(Chapter9 Sq.F[.Floor Area Valu$'
, (commencing with Setting 70M)of Division 3 of dm Business and Prolamines Coxi or
�.. that he Is exempt thcrUrom and the basis fm the alleged axemp ion.Any violation of
Section 70315 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more then five hundred dollars($500). 36940002 . 00
❑1,as owns of 0¢property,or my employees with wages as their sale compenmdon,
willda thowark.and the structure isnotimended mrmffered forma(Sec.7044,Business Required Inspections
and Profession,Code:The CowactoYwto e ns
s Lime Law does not apply an Owner of q P
property who builds or i mpromm thereon.a nd who dues tach work himself or through his
own employees,provided that inch improvements are notimmnded arm@red for sale.If,
however,the building Or Improvement is sold within am year of completion,an,owner-
builder will have the burden of proving Nal he did mus Wild Or improve far purpose of
"In.).
❑I,as Owner of the property,am exclusively convecting with licensed canumtors to
contract use pmject(Sec 70x4.Bwiness and Professions Cade:)The Contractor's LI-
ccwc law does not apply to an Owner of property who Wilds or improves thereon.and
who contracts for such projects with a contractor(a)licensed pursuant to the Convamor's
License Law.
❑1 am exempt under Sec ,B&P C for this moon
Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury am of Ne fallowing declaration:
❑I have and will maintain a Cerdfic.mmf Concent to self-InsumforWaheYsCompcn-
netion,u provided for by Section 3700 of the labor Cede,foe the performance of tho
work for which this permit is issued.
❑I have and will maintain WWker'e Compensation Insurance,u required by Section
3700 mf Ne labor Cade,ran the ismimmancemf Ne wash forwhich Nin perm,is issued.
My Work es Compensation lasuume carrier and Policy number are:
Carder:`d'uk&k A—tt4_0414tcy Na.:I%eCG 3533Io3-0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not6ecomPleted ifthe permit Isfwmwhundreddollus(5100)
or los:)
1 modify that in am performance of Ne work for which this permit is Issued.I shall not
employ any person in any mmwr an as in became subject In IN Workers''Campematlon
Laws of Celifomia.Dem
Applicant
NOTICE TO APPLICANT:If.after making this Certilicam of Exemption,you mould
become subject an Ne Worker's Compensation provisions of me Labor Code,you mum
0Z forthwith comply with such provisions or this permit mall be deemed revoked.
r~�.. CONSMUCfION LENDING AGENCY
(-+ I hereby affirm that there it a construction lending agency for the performance of
ai > the work for which this permit is issued(Sec.3097,Civ.C.)
GQ L ndcr's Name
0.z Lender's Address
U 0 I certify that I have read this application and sum Nal the show information is
ns F Cartmel.I agree m comply with all city and county onlinsmes and nam laws relating to
DU building construction.and hereby authorize repmsentstives of this city to enter upon the
W above-mentioned property for inspection purpeux
(We)agree to new,Indemnify and keep handless the City of Cupertino against
ti h limilithes,judgments,casts and expenses which may in any way sceme again(mid City
U 7 In consequence of Ne{ranlin{of this permil.
F7 APPLICANT UNDERSTAN S AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREG LAMO -
2a/ d Re-roofs
Signa of ApplicardVContnc Dam
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or fuwrc building Occupant etre,or handle hasandous material
,fined by the CupeNw Municipal Cade,Chapter 9.13.and the Health and Safety
Section 355330)7 t4+m, All roofs shall be inspected prior to any roofing material being installed.
Yes
Will the applicant or future Wilding occupant am equipment Or devices which If a roof is installed without firs[obtaining an inspection,I agree to remove
emit haurdnus air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
Chance?
❑Yes �Vu
I have mad the hasaNuus mamrtalsnequimmmtsunder Chapter6.95 mfthe Califor-
nisHealth&Safety Cade,Sections505.35533 am135534.I understand thatifNc Wilding
data not currently haw a enml.jFyit i6 my responsibility to amity the Occupant Of the
requirements which mum Wme nuimumceofa Cegmcamafoccu ancy Signature of Applicant Date
a, i d'�2-Y fo S' All roof coverings to be Class"B"or better
Owner prauthorixed agent Dam
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