05030267 CITY OF CUPERTINOxa :
BUILDING DIVISION PERMIT 61
CONTRAC"�TURIN'F'URMATTOi
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT"°05030267
OWNER'S NAME: PERM]T ISSUE DATE
2005
E: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITEC(ENGINEER: BUILDING Pli INFO
BLDG EO PLUMB MEOCH
glop LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby CMme that I am licensed under previsions of Chapter 9(commencing
am with Section 7")of Division Sof me Business vb Professlmu Codo.and my license is
< mf11f.m.mdeffect. y,� d j NEW CONDOMINIUM
S 3 Licence CI Lk.I
Dam true wt OAtyL_ 1193 SQ. FT. LIVING AREA
ARCHITECTS DECLARATION
I understand my plans shall be used as public rtord, BMR UNIT/ NO CONSTRUCTION TAX
],,U
Licenced Professional
OWNER-BUILDER DECLARATION
5i 1 heathy efr m that 1 em exempt from the Contractors License law for the
i a O following moment.(Section 703 1.5,Bwueee and Profession Cade:My city or county
u�$ which requires a permit or CansudcL ager.hnphrw,demolish,or repair any suuclum
Fxi prior he its issuance,also acquire me applicant for inch Permit to rite a signed summers
<
that he is thousand pumuanttoOur Provisions ofdon,Commutes ucemclaw(Chapter9 Sq. Ft. Floor Area Valuation
F�S (commencing with Senlon 1000)of Division 3 of 11th Business end Prakssians Cnde)or $138101
.. that he u exempt therefrom and me basis for tito alleged coomption.My violation of Y
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy�1
not mart man fins hundred dollars($500).
p y '7�
❑Lomowner of me pro perty,amyemntende withwageas cele(ante 044,8 sins,
will dome work Cod the he Comb not intended,Low talde nn t apply h an,water or
sena enywhlons Cede:The Canwnors and
who Law dm not apply lf rt owner of Required Inspections
propeny who b,provided
imprnwu thereon,and who doe smchwet himself ormromle his
own employee,provided mat each Improvements am maintained of milled n,for mu.lf.
however,me building or Improwmenl is mid within mm year of c Improve
r me owned
builder will haw W burden of proving that he did not build or Improve for purpose of
Bele.).
❑1.as owner of the propeny,am exclusively contracting with licensed contractors to
constrain me project(Sec.7014.Bastnw and Professions Cade:)The Contractors U-
cause law does not apply to an owner of property who builds or hmprows theman,and.
who eonwc,for two projects vim amnuactar(s)thousand purawnt to me Contractors
License law.
❑I am exempt under Seas .B At P C for this rescan
Owner Dau
WORKER'S COMPENSATION DECLARATION
410 I hereby affirm under pewlty of perjury arc of the following declamiom:
❑ thaw mW will maintain aCeniGamof Camentta m161nsum for WorlmesCmnpen.
norm,om provided for by Section 3700 of the labor Code.(m the performance of the
wart for which this permit is Issued.
❑1 haw and will maintain Workers Compensation Insurance,as required by Section
3700 of The Labor Cade,for the performance of the work for which this permit Is issued,
My Workers Compensation Imeamm,carrier and Policy number art:
CmH.,:7_IJ4JGH-A,1tXiC�pon=yN1.:We7.I03tDJ-0
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectlm need rant be completed if me permit is foronc hundred dollars(5100)
aur less)
1 madly met in the perfmmancc of me..Or for which this Permit is issued,I W11 not
employ any person in any manner an as as bccomembject to the Workero'Compewdan
lawa of CaRromm.Dam
Applicant
NOTICE TO APPLICANT:If.after making this Carcinoma of Exemption,yrs should
become whist to mo Workers Compensation provision of the later Code,you most
rJ O forthwith comply with such provision at this Permit shall te clamed remand.
Z 55 CONSTRUCTION LENDING AGENCY
1-a Ihereby alarm that mere is a construction lending army for the performance of
Cr7 mue.e murk far which this Permit Is issued(S 309'1,Civ.C.)
4 Q Lendch Name
Z Lenders Addmas
U O 1 cenily that 1 haw read this application and sum that the show information U
{L P corms.I agree to comply with all city and county ordinances and sante laws relating to
C U building construction.and hereby mothers rep usertativesofthiscitytoenteruponme
{27 above-mentlaned pmperty for interaction Peposes.
(We)agree to mw,indemnify and keep harmless the City of Cupertino against
vs rrAA liabilities,judgments,costs and expenses which may to my way ammo against said City
U Z to consequenceof me grammg of this pcoatI
.. APPLICANT UNDERSTANDS AND W COMPLY WITH ALL NON-POINT Issued by: Date
SOURC RECUTATIONS
694f AS— Re-roofs
Signature of pliani/Contrctorm
HAZARDOUS MATU15LS7DISCLOSURE Type of Roof
Will thin applicant ser forum Wilding aadpanr atom whanAle hazardous material
as dented by the Cupertino Municipal Code.Chapter 9.12,and me Health and Safety
Conn,Section 25532(.)? All roofs shall be inspected prior to any roofing material being installed.
❑Yef (�fsO
Will me applicant or future Wading aaupent nse eyuipmcm a devices which If a roof is installed without first obtaining an inspection,I agree to remove
It hazardous air comumin m as donne by the Bay Arta Air Quality Management all new materials for inspection.
District?
❑Yes
I have mW the hmardnuamamrials roquimmenu underChapwr6.95 of the Califor•
nice Hcol"Smfely Cade,Satlom2551)5,25533 and 25534.1 understand mmtifthe building
does not currently haw a wnam,mat Ity responsibility to nam'y the meupant or the
requirements which must be met It sor dome of a cadficato Aram ey. Signature of Applicant Date
owner the ived agent All roof coverings to be Class "B"or better
a