05030284 CITY OF CUPERTINO -
BUILDING DIVISION PETMUT CONTRAC�TORpIN0511kk�01!I
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT"0.05030284
OWNER'S NAME: PERMIT ISSUE DATE
g; SANRARY N0. CONTROL NO.
(510) 385-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
�tsp Zp LICENSED CONTRACTOR'S DECLARATION Job Description
01 Wrathy affirm Nat 1 am liceved under Provision$of Chapter 9(commencing
with Section 7000)afDivWan 3 of the Business and Profusions Code.and my license is
^ in full form and eITem
Llcmwecl L'e. N1g/ 6Jl NEW CONDOMINIUM
c
Dat co -noustor_1t e TETE 1116 SQ. FT. LIVING AREA
0 ARCHITECTS DECLARATION
I understand my plans shall W used as public accord
7y
G Licensed Professional
OWNER-BUILDER roan is from
DECLARATION
a0 1 hereby.Rens on I am escmpt from IM CAnn.la o License Law for IW
0 o fallowing won.(section 7031.5.Business and Profession Code:Any city or county
$f<i which requires a permit re cores IN alae improve,h permit
t m acpalr any scutum
�Z i
prior u.Bemused pursuant
urb ant to IN lW appvision nt ofTar such permiuo 0e se tAw(Chapter
< thatheb0ccnsed pursuant7")pmvi.iou ofthe ofthcBusiness
Contractor's License Professions
Co6ter9 Sq.Ft. Floor Area Valt}�tiltrB188
(cat he Is rromng pi orefon700d)of basis
rth Al aged c,end rm.Any vi Cale)tar
$ Net be 4 uempt therefrom and Ne bub far the alleged eump0on.Any violation of
Section 7031.5 by Any appolesnt for a permit objects the applicant o a civil penalty or APN Number Occupancy Type
AM more Nen five hundred dollars(5500).
36940002 . 00
Ql,uawmr ofthe proprsty,eemY employers with wagesu Ne'n.le campen,etion,
will do the work.and thestrucure bm,inended oraffeml thrash,(Sec.70u,Business Required Inspections
and Professions Code:The COmssemh Liam¢Law does tut apply m e ns an corer of q P
property who Widdaar improws tWmon•and who desea,echweekhimeselfor through his
own employees,provided that such Improwments are notinended or offered founds.If,
however.the building Or Improvement is sold within am year arcompdedon.Ne owner.
Wilder will have the burden of proving that W did ON Wild An improve for purpose of
um.).
❑1,u Owner of Ne property.am exclusively connecting with licensed contractors to
construct the project(&e 7044.Business and Profusions Cod:)The Contr.rors Li-
mut Law docs not apply to an owner of property who Wild or improves thereon,and,
who convects for such pmjeca with a conuanor(s)licensed pmsnsnl m the eo.mloes
License Law.
I am exempt under Sec. ,B its P C for this rutin .
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby aam under peully of perjury No of the fallowing dedsommu:
I low and will ma"'Ant•CuORmte ofcanaent an elf-insure fee Warke'.Camp.- -
sation,As provided for by section 3700 of the labor Cade,for the Performance or the
work for which this permit is issued.
❑1 haw and will maintain Worker's Compensation Insuonce,u requited by Section
3700 of the Labor Code.for the performance of the work fm which this pemtit Is Issued.
My Waukee.Compeuadon Insurance w u�n'it,and Policy number are:
Gnier.??y4,c# /Iv"G7�/!�f✓ policy No.:wC Jr?3/0;—O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need nut W.mplemd VON permit is froom hundreddellats(SIM)
or less.)
I cenffy Not in Ne pmIUMMUce of the work for which this permit is issued,I shall not
employ any person In Any mannero As in become subject 10 Ne Workers'Compensation
Laws of California Data
APPlie.t
NOTICE TO APPLICANT:If.after making this CeoiRmte of Esempion,you should
became subject an the Worker,COmpcuatian provisions or Ne taWr code,you most
.J ZO fombwiih comply with such provisions or this POMUL shall W deemed revoked.
z ti CONSTRUCTION LENDING AGENCY
('r (hereby of im that there is construction lending agency for the performance of
lx> the work for which this permit b issued(Sec.309'1,Civ.C.)
0.0 Landes Num
2 Lendeh Add.
U Q I ceNfy that I have road this application and,tate that 0e eWw,informadun b
I city and county ordinances and state laws elating an
O building e.struction,and hereby authorrins . wa
i>a mpnatiof this city uv
ever upon the
W ahovementionW property for inspection PufPOWL
a (Wc)agree to taw,indemnify and keep harmless the City of Cupertino against
In Ilabilife,judgments.costs And expeuca which may In any way...against and City
C.)zI.APPLICANTCUNDERSTANDS of I.Inuums of tAis permit.WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR EREGULATI NS.
g 0 J Re-roofs
ignswu3,parApplicauntXontruccus, o
HAZARDOUS ATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant more orhandle hArANUes material
an dc0ncd by the Cupertino Municipal Code,Chapter 9.13,and the Health and Safely
Code.Sued..23532(a)7
0 Yes I<— All roofs shall be inspected prior to any roofing material being installed.
Will Ne applicant or mom building Occupant are equipment or device,which If a Toof is installed without first obtaining an inspection,I agree to remove
it huaNnu air cumin. u d by theBq Arca Air Quality Maugcment all new materials for inspection.
District?
0 Yes No
I have mad the hazardous materials mqudmm urs under ChaPter6.95 of the Califor-
meHealth At Safety Code,Sections 25505.25533 And 25534,1 undessmrm MAtlfthe Wilding
does not currently haw A tent.Net it is my nAhility m notify the=up.t of the
requirements which mon Wmct priorui ar.ccthBcamoroc U tr. Signature of Applicant Date
owner ori>edagem 71 DadAll roof coverings to be Class"B"or better
L