05030269 CITY OF CUPERTINO ' :
BUILDING DIVISION PERMIT CONTRAC�TOR�INFI.tMATIUi`t ,°
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT"°05030269
OWNER'S NAME: PERMIT ISSUE DATE
T)RT
E; SANITARY NO. CONTROL N0.
(510) 38 -0121
ARCHITECTIENGINEE
0 385-
ARCHITELT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p
ri0o LICENSED CONTRACTOR'S DECLARATION Job Description
+� 1 areby grim Het Ism Iimnmd under provisions Of Chapter 9(commencing
w. gcedan70M)afDivtat$n 3af the BusinessandProfessimis Code,andmyliccnaou
in full forae asand cRect. �}
rt z Lkon Lk.« Lf%k Ol / NEW CONDOMINIUM
olg' Dam Conlmnar L- n + rL 1193 SQ. FT. LIVING AREA
ARCHITECTS DECLARATION
I understand my plans mall ism mind u public becoms
c Clamored Professional
OWNER-BUILDER DECLARATION
in
I 1 hereby sfibm that 1 am exempt from dm Contractors Ueenm Law for the
M 0 following moan.(Section 70315,Business and Pm(essiuns Cock:Any city Or aunty
$ which require,a permit to anuract,alcor.improve,demolish,or repair soy structure
prim a its Issuance,also ruquires�applicant for such permit m rile&signedwment q ay�[t�®101
< tat heisllanseJ ursuanttodte visions of the Conwctor'sLimium aw(Chapter9 S Ft. Floor Area Val
al (commencing with Section 7000)of Division 3 of the Business and Profession,Code)w
that he la exempt therefrom and the basis far the alleged exemption.Any violadon of
Section 7031.5 by any applicant far a permit subjects the applicant in a civil penalty of APN Number Occupancy Type
not more man rive hundred dollars($500).
❑Lasownerk and propony, remycmntendea with wages as Mailwincompensation,Business
36940002 . 00
will dodmwwk.and : O Cmels not uresLi erre,ed offered do s not apply 7044,Business
of Required Inspections
and Professions Cade:TO Comuecmrg Liana Law done not apply a an owner of 9 P
property who bulldaor improve,Hermon,andwha dassvhwork himself orlhrougb his
own employes,provided that such mProwmants ate net ew of completion,
mpletred torula.i(.
however.the building orimprovementlshathwithinoneyearofaoplefortheawner-
builder will have the burden of proving that a did wt build m Improve(w purpose of
❑1,u owner of He property.ma exclusively contracting with Ban conuacmn m
construct He proimn(See.70/4,Business and Prefeuiov Code:)The Contractors U.
ave law it=act apply to an owner of property wa builds or improve women.and,
who contract for two projects with s anwcmr(s)liaved pumm nt as the Contractors
License law.
❑I un exempt under See .B g:P C fill H4 mason
Owner Dam
WORKER'S COMPENSATION DECLARATION
40 I hereby a ire under penalty of perjury ane of Ne following dcalan0ov:
❑Ihawandwlllmainuina Ceniframof Conunlmulhlasumfar Worker',Compeo-
urian,as provided for by Section 3700 of Me,labor Code.for the perfo mmom of the
work for which His permit is issued.
❑I hove and will maintain Workers Compensation Insurance,as required by Section
3700 of He Labor Cade,for He performance,(the work for which His permit is Isevd.
My Workers Compensation Insurance carrier r-and Policy number am:
Caller""(/AfG// '411t* ity No.: ? 'rd
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This miction neral trot becompleted 0 tic Permit is fm ane hundred dollar($100)
or kis.)
I unify,Hot in He performance of the work for which His penin la issued,l shall not
employ any pawn In any manner was in become subject to dm Warker'Campenudml
Law,of California.Dam
Applicant
NOTICE TO APPLICANT;IL after making Ibla CenlOcale of Exemption,you should
become Subject a the Worker's Compensation provisions of Oc labor Code.you mol
w,O foMwi th comply with such provisions in this permit shall be deemed mvoked.
z 5; CONSTRUCTION LENDING AGENCY
[.r I hereby affirm that More Is a construction lending agency for He perimmance of
C tie work for which this Permit is iomd(Sec.3097,Civ.C.)
6Ui Q Iemices Nurse ,
a z Lenders Address
U0 1 anlfy Ho 1 haw and this application and Was that tier shove Information i, '
ty F Carted.1 agree in comply with all city and county ordinances and sum law mining to
O U building construction.and hereby suHorim mPrrsenutiws of this city te enter upon the
til abow-mendamd propeny for inspecdo purpmes
C (We)&gra in taw,indemnify and keep hatmha,the City or Cupertino ageivl
y liabilities,judgments.maw and exporters which may in any way amrre&game Said City
in coni gonee of the grating of His
w. APPLICANT UNDERSTAND D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGU nONS.
Re-roofs
Signa of Appliant/Conmcmr Dow
HAZARD° MATERIALS DISCLOSURE Type of Roof
Will thc applicant ur(uem building occupant comm orhandlc hazardous material
as defined by the CuNnino Municipal Code.Chapter 9.13,and the Health and Safety
Code,Section 35532(e)7L' All roofs shall be inspected prior to any roofing material being installed.
❑Yea 695
Will the applicant or future building wcupml use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
colt hazardous air conuminava o defined by the Bay Ana Air Quality Management all new materials for inspection.
District?
❑Ycs
I hue road the hasardons materials mqubements under Chapter 6.95 of the Coffee.
nil Hulth k SalmyCodc.Savwu 35505.25533 aw175534.I UMermatm that if dm building
does not curenlly cow a tenant,that it u my r povibilily to notify He meupant of Me
requimmcnu which must be met be met pri�f a Certificate Ofticu}e� Signature of Applicant Date
�L¢j7. � /� All roof coverings to be Class "B"or better
Owner uffdlho, em ream