05030292 CITY OFCUPERTINO77777rya�« >x
BUILDING DIVISION PERMIT nCON;TRACTOR4NFORMATI0N f
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO 05030292
OWNER'S NAME: PERMIT ISSUE DATE
E; SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITECr/ENGINEE
0 385-
ARCHITECr/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB
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LICENSED CONTRACfOWSDECLARATION Job Description
I Mreby afnrm dml l m licensed under provisions of Chapter 9(commencing
n�1 with Section 70(IU)OfDivW n3 of the BmmusseM Pra(essium Code.and mylicrnseis
ons mmnlocceeCis ern J1 9 3 r NEW CONDOMINIUM
n:emecl c vacmr lir C 1116 SQ. FT. LIVING AREA
?p ARCHITECTS DECLARATION
$+ I unclum and my as
pians shall be used public mcmNa
c Licensed Prufoastansl
OWNER-BUILDER DECLARATION
Z I hereby affirm that 1 am exempt fmm the Contractor's License Law for the
p O following mason.(Section 703 1.5,Business and Profemluns Code:Any city or county
$ which requires a permit to construct,alter.Improve,demolish,Or repair any smuctum
prior m iu Issuance,alau requires drt applicant forsuch permit m Rle s signed statement
dral he IS licensed pUMOnt In the proviSiOm of the COnrsom''e License Law(Chapter 9 Sq. Ft. Floor Area Va($
�$ (commencing with Section 7000)of Division 3 of the Business and Professions Cade)or
E F 5 that he m exempt donefrom and the basis for the alleged csempdan.My viWadon of
Section 7071.5 by any applicant for a Permit Subjects the applicant to a Civil penalty Of APN Number Occupancy Type
tet more thin five hundred dollars(5500).
❑1,m Owns arthe proPmr.O my wvlayeea saw w.ge,Aa d eb,am wmpe ts an. 36940002 . 0 0
will do the work and themunuse is nal intended moReud Wadc(Sec.7011,Beat. Required Inspections
and Profeuians Cade:The Conuacmr'a License Law te e domi apply m an Owner of q P
property who builds ar imprmes Ihemon,and who does such work himself Or through his
Own employees.previded that Such impro emanuart not Imendal mOEaed forams.If.
however,the building or improvement is Said within on year of mmpletim,the owm.
Wilder will have She burden of proving that be did not build or improve for purpose of
Sale I.
❑1,as owner of the property am exclusively connecting with licensed commons to
construct the projen(Sec.7W,Business and Professions Cade:)The Cm m1m`a Li.
Came Law dam not apply an an Owner Of property who build.or hmprom daemon,and
who contracts for Such projects with a conuacon(O licensed In uuanl to the ConwnaYs
License Isw.
❑I am exempt under Sew ,B A P C rte this reason
owns, Dam
WORKERS COMPENSATION DECLARATION
1 beacbyru
SM.under penalty Of perjury one or the following declarations:
haw and will mainuin a Ceddficam of Come n to selyinsum for W~sCompen-
mile..as pmvidod fa by Sidon 3700 of the Labor Code,for the Performance of the
work for which thh permit is issmd.
❑1 have and will mammon Worker's Compensation Insurance,as acquired by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued.
My Workefs Compensation Insurance carrier andPolicynumber art:
Carder:'77,islfcN �•1"47yif C Policy No.:WG 3S
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisuctlon need nothecomplemd if the Permit is foranc hundred Collars($100)
or less.)
1 certify that In the perfamanec of dac work for which this permit is issmd,I Nell not
employ any person in any manmrSu m to become subject to las Workeri Compemadan
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,aAct making this Certificate of Exemption.you should
become subject an the Worker's Compensation provisions of the Labor Code.you mute
OfOMwith comply with such"via=or this Permit Nall be deemed moked.
Z CONSTRUCTION LENDING AGENCY
[r I hereby arm that dmrt is a construction lending agency for the Performance of
C,7 the work for which this permit Is issued(Sec.3097,Civ,C.)
W�Q Lendcr',Namc
D z Lender's Address
U 0 1 Codify that I have mad this applirnion AM sum that the abuw information is
comm.I acme to Comply with all city and munly ordinance,and mm lawn misting IO
0 U Wilding construction,and hereby authadw represematim of thts City to emus upon do
[r7 abn--omo it and property for l"Pection purposes
C5� (We)agree to taw,indemnify and loop hamlets the City of Cupertino against
r,y y liabllides.jud{menu,costa and expenses which may In my my meson against said City
U,Z bun em sequence of thegranting Of this it.
^^ APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by:9 Date
SOURCE REGU ONS.
8 '1 B Re-roofs
Signa fApplica uconuanar Dele
HAZARDOUS PATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store Or handle haxsrdous material
as defined by the Cupertino Municipal Cade,Chapter 9.12.and the Health and Safely
Code.Section 25532(a)7 � All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building Occupant use equipment or dcvdcm which If a roof is installed without first obtaining an inspection,I agree to remove
havsrdous air cen...mantt as defined by the Bay Area Air Quality Management all new materials for inspection.
Disuict7
❑Yea u
I bw read the hauNous materials mquiremcnu under Chapter Q95 of the Califm.
nu Health A Safety Cade,See..25505,25533 d2553/.lundcrmrm that if the building
dote Out C.11y have a mnanl.that it E a aponsibilllY m ratify the aavpanl Of the
requimmenl5 which mute met prior ce of.Cenhficam of Occup Signature of Applicant Date
�,
ownera�.r ad�<dagent —� All roof coverings to be Class"B"or better