05030285 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INIFORMATIUIV ':
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMITND.05030285
OWNER'S NAME: PERMIT MUE DATE
E; SANRARY NO. CONTROL NO.
-0321 BUILDING PERMIT INFO
BO EO PLUMB MECH
O
�0o LICENSED CONTRACTOR'S DECLARATION Job Description
uJ 1 leartby affirm that 1 Am licensed under provision of Chapter 9(Commencing
wWSecdo 7")of Diviai Jaf the Butineaa and Prafcaslnn Cede,um mylicenxu
I-.full-=.'me ercnct. I NEW CONDOMINIUM
j z License CI Lie.N
0 Con snor L� ti 1116 SQ. ,FT. LIVING AREA
ARCHIIECI'S DECLARATION
' understandn i understand my parts shall x used As public memmor
Z
ir Licensed Professional
OWNER-BUILDER DECLARATION
I I hereby Affirm that I am exempt from the Commences License Law for the
p O fallowing meson.(Section 7(D 1.5,Bnincas and Profession Cade:Any city or county
$� which requisea a permit in cnmroc4 alma improve,demolish,or repair any stroctum
F nye poor in its Issuance.also requires the Applicant for such Permit to file a signed statement
F that he is licensed pursuant to the provisions or the Conhol License Law(Chapter 9 Sq.Ft.Floor Area Value 188
a( $ (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
..
that he u exempt thmefrom and the basis for the alleged exemption.Any violation of
Secden 7031.5 by any applicant[a a permit subjects the applicant m A civil penalty of APN Number Occupancy Type
not more than Ove hundred dollars ISM
❑I,asCramer car am property,Car my aoployees with wages as dealt mu compenodon, 36940002 . 00
will do the wort and site struchm is trot imended or offered fos We(Sec.7044,Budnee q RC UIIed Inspections
and Profession Coda The Commence,,Llama law dma act appy m Cower an oer a( P
property who bis ods nr improves dmmon,and who dues such work himself or through his
own employees.provided thatsuch improvemmuare not Intended moQewel torsate.ll.
However,the building as improvement Is mid within aro 3w of completion,du Owner.
Wilder will have t a burden of proving that he did nn build or improve for purpose of
ate.).
❑I,as owner of the property,am exclusively commuting with licensed conveners In
construct de project(Sec.7014,Business and Profession Code:)The Contractees Li-
cense law docs not apply m an owner of property who builds or Improve demon.and,
who contacts for such projects with a coneracter(Q 0censed pursuant no the Conmetoes
License law.
❑1 am exempt under Sec. .a stP C far this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
I hertby arcism under pwry of perjury aro of tlu following 6slaratiana: '
❑I mw and will maintain a CaNOcam OfCommal roself4num fm Worker's Compn.
nation,as provided for by Section 3700 of the labor Code.for the performance of the
work for which this permit is issued.
❑1 have and will maintain Worker'Compensation Insurance,as required by Section
3700 of the Labor Code,for the performance of the wart for which this permit is heard.
My Worker's Compensation Insurance carrier A/nnd Polity number am:
Cerler.7VAL(LH .41 e–)L(e PolityNa.:"3!23ItyI
CERTIFICATE OF EKEMMON FROM WORKERS'
COMPENSATION INSURANCE
(This senln need coat Mcompleud Ethe permit Is forme hundred dollars(SIM) '
or less.)
1 certify that in the performance of the welt for which this Permit la moved.I Anil not
employ any person in my manner An As in become mbjwt a tM Workers Compensation
taws of Cs if nein.Data
Applicant
NOTICE TO APPLICANT:If.After making this Certificate of Exemption,you should
became mbje,in the Workers Compensation provisions of ac Labor Cade you mm
�Q forthwith Comply with such provision or this permit shall x deemed revoked.
?► CONSTRUCTION LENDING AGENCY
[.r Ihereby am.da,then is a consvuctinn mndingagery far the perfurmeneof
C> the work for which du permit u issued(Sec.3097.Civ.C.)
QLendern Name
07• Lenders Add..
U0 I certify the I have read this application and Nm Chat the chow information is
{L. coney.I agree to campy with all city and county ordinances and Sate lawn matar to
0 building construction,and hereby amboom representatives or this city to enter upon the
LCl .have-mentioned property for impeamn purposes
(Wo)ague to an.indemnify and keep Inc nleo the City of Cupertino against
Taj) Imbillfies.judgments.coSa and expenses which may In my way Amue Alliwit said City
()Z to eensrgeeneo of the granting of this permit.
., APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU REGUL.A ONS. ^ 1 r
�r Re-roofs
Sigmas
D&
HAZARDOUS
HAZARDOUS TERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant mom or handle haerdous material
As de dined by Ou Cupertino Municipal Code.Chapter 9,12.and the Heald and Safety
Cole.Section 05532(.)? All roofs shall be inspected prior to any roofing material being installed.
Yee
Will the applicant or future building Occupant use equipment or devices which If a roof IS Installed without firs[obtaining an inspection,I agree to remove
mlt haerdous air conwounmts as defined by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes l
1 have mad the huanlws mammals requircmenu under Chapter 6.95 ofde Califor.
nu H.Al6SdityCode.Smtid.25505.25533and25534.1unMrsu ifthe building
Joos rot currently hew A mnm4 du it' responsibility m notify de ocevpmn of du
rtquirt,q�nuwhkhm metPm. anceofaCcniMateof apmuy. Signature of Applicant Date
��2yIeS All roof coverings to be Class"B"or better
Owner mhaoved aCem o�