05030264 CITY OF CUPERTINO aI s + + ¢ `� ""roe'*' '" ` " •
BUILDING DIVISION PERMIT `CONRACTQT.t TN'!?f0'KMATIONr
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT 440.05030264
af)500 TOWN CENTER IN
R'S NAME: PERMIT ISSUE DATE
S R
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHREC(ENGINEER: BUILDING PERMIT INFO
BLDGO O PLUMB MECHO
Sop
LICENSED CONTRACTOR'S DECLARATION 7obDescrition
r/ I hereby sauce that I me licensed under provismax of Channel 9(cnmmendng P
with Section 7000)of Division Sof the Busimasand PmfeWm Code.and my lice=Is
+ Imfull forme andeffect. e NEW CONDOMINIUM
3 4 Lkenu Cl Lice y l 43 j
Dam Contractor I✓t dNEIL 1193 SQ. FT. LIVING AREA
iARCHITECTS DECLARATION understand myplamehallhe used upublic amrdt BMR UNIT/ NO CONSTRUCTION TAX
a and Licensed Professional
p OWNER-BUILDER DECLARATION
A I I hereby 4MM that I am exempt from the Contractors Licence Law for the
p o following mason.(Section 703 1.5,Business and Prokssiuu Cade:Any city or county
S$ which requires a permit to Construct.after.Improve,demolish,or minor my stmcmm
prior to its issuance,arm requires the applicant for such permit o file a signed statement
<
uses he is licensed Pursuant to the Provide.of the Contor.Ucce.Low(Chapter 9 Sq.Ft. Floor Area Valuation
15$ (Commencing with Secdon 7000)of Division 3 of Me Business and Profeuiom Code)or $138101
Mat he I.exempt themhmn and the basis fm the alleged eumption.My vi OOM of
Section 7011.5 by any applicant for a permit subjects site applicant to a civil penalty of APN Number Occupancy Type
oat more than M1w hundred dollars($500).
❑I,u awnm of die pivpmy,m my employees with mgu u reek mie Compewdon,
will do thew•ork,and the muctme 6 nutlntended or0cmd fmuk(Sao.7044,Business 9Required Inspections
and Profamoss Code The Contractor,Limme Law does rot apply m an owner of q P
property who buildsor improves the con,and whodmsuch workhimselforthough his
awn employees,provided that veer Imps old within
oat intended mp"on,fm.k.Ir.
however.the building Me orimprovement
an otementg Coldwithinaneyear of mprvfar the rose of
builder will haw the beNcn of proving Nat be did not build or improve fm purpose of
ask.).
❑1,as owner of the property.am exclusively convecting with licensed contractors to
construct the pmlect(Sec.7014,Business and Profwions Cede:)The Contractors U.
muse Law does not apply to an owner of property who hulks or improves dsrson,and
who contacts for such pmjeeta with a comeactor(s)licensed pursuant m the Conmactor's
License Law.
❑1 am exempt under Sea. .B d P C fm Nil won
r Date
WORKER'S COMPENSATION DECLARATION
1 hereby offers under poetry of perjury rem of Ne fallowing dedlamauoo:
❑I haw and will maintain a Certificate of Coruentto self-insure for WorhY.Compen-
.don,as provided for by Section 5700 of the Uher Code,fm the performance of the
work for which this permit is Wood.
❑1 ban and will resonant Workeri Compensation Insurance,u acquired by Section
5700 of the labor Code,for the performance of the wort fm which this permit is Issued.
My Workers CIo�mpeasadon Ineuranm carrier and Policy number ase:
Canien?AYAJO-/,'vvMLA--"Policy No.: ICG 3S)3/03'0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
OTls section need nomccomplemd Iftbe Permit is faronchundreddorW({100)
on less)
I certify diet in the Performance of the work for which Nie Permit m lured.I mall not
employ any person in my mamerm as to become subject on the Workers'Compeasadon
Laws of California.Dam
Applicant
NOTICE TO APPUCANT:If,after making this Cer ifiam of Exemption,you should
become subject to the Worker's Compensation provisions of the tabor Cade,You mot
OZ forthwith Comply with such Mvisions or this Permit shall be deemed revoked.
z O CONSTRUCTION LENDING AGENCY
[r Ih.mbyafrum that them is a construction lending agency for the Performance of
fx the work fur which this permit Is issued(Sec.5097,Cih,C.)
Q Undoes Name
7 Z Lenders Add..
U Q 1 notify that 1 ban no this application and sum than the above Information Is
IL F~- corset 1 agm to comply with all city and county ordinances and tote lave relating to
Ubuilding construction,and hereby author=representatives of this city to color upon do
LII ahow-mentioned propcny for instruction purposes.
d
(We)agree le an.indemnify and keep harmless the City of Cupertino against
Uy in consequence
or th,cmnandof th swhich may in any way eec7mte agsiut aid City
V IL
APPL�ANTeUNDERSTANDSthrN� VILL COMPLY WITH ALL NON-POINT Issued by: az Date
SOURraE REGULATIONS. .
Re-roofs
Si{.tort ppliant/Convecmr D e '
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
WIII the applicant ex future building occupantsmme of handle Incautious material
fined by the Cupealve Municipal Code.Chapter 9.11.and the Hcalth and Safety
40.Section 15531()? All roofs shall be inspected prior to any roofing material being installed.
❑Ym
Will the applicant or future building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit lamAndoes air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District? 1�
❑Yes L7nu
1 have mad thelcoard...materials requirements under Chapter6.95of the Collar.
nie Hoabse k Safmy Cad.,Sadona15X15.23533 and 15534.1 understand Maifthe building
dues not currently have a tenant Los t I.my mepomlbility to notify Me map.,or Ne
requirements which must be met ' to lvuance ofa CertiIII of tic panty. Signature of Applicant Date
.�.7.a — / e 2.% All roof coverings to be Class"B"or better
Owner or 01hodytila em 9V U.¢
C