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05030293 CITY OF CUPERTINO BUILDING DIVISION PERMIT. 4C01TRACmC1R INk'q"IIATI©N, BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT 110.05030293 OWNER'S NAME: PERMIT ISSUE DA' 10081 2005 NE: SANITARY NO. CONTROL NO. (510) 385-0121 ARCHI'IECTIENGINEER: BUILDING PERMIT INFO O ELECT PLQ MECH O +I om LICENSED CONTRACTOR'S DECLARATION Job Description U 1 hereby affirm that I am licensed under provision of Chapter 9(commercial P with Section 70(IB)of Division S of the Business and Professions Code.ad my licemn,is m ran fora ad affect. Lj q/a d 3 / NEW CONDOMINIUM j e Z License I Lk.a Do Date Cunlnux L✓rZ ( 1116 SQ. FT. LIVING AREA 3 ARCHITECT'S DECLARATION 1 understand my plana shall he used u public namucls s tea Licensed Professional OatNEmBUILDER DECLARATION 0 53 1 hme a aRtrm that 11. exempt from the Contractor's Licence Law for the S O o fallowing recon.permit i 71131.5,Business and improve, de nu Coor:;Any city or county $�a which requires a pmmlt ac cnnaw:L plug impmw,dPermit,or repair ed structure pilar a its anon c,oho mqn the the applicant for manCor permit m file a signed Chapman =idmnumaanscdpunuanttoucofDivisionfthe Bustinadauncenwlaw(Capur9 Sq.Ft.Floor Area Val 'B1918 that M Is exeming pt Sanious ad of Division r of to alleged essand Profession laode)nk)or of � Out a b exempt therefrom ad the buts for the alleged ewmptim Any violation of Section 7031.5 by my applicant for a permit subjects also applicant to a civil penalty of APN Number Occupancy Type 11th moa d w five hundred dolit(5500). 36940002 . 00 wi Lu ownerof the prommymnpmymvimwageu Nev cele 044,BuWw, will Pr Umwoit.n sed abashment.he CoB matmes U dax Law dosed not apply 7011.Business sed Profession Code:The Contnamn Lkense Law dm not appy lf a owner of Required Inspections pweenywholoutids i impromdemon,sed whodaosuchwork himeelrad through his own cmploym,provided that such improvements in not inun for aoQarW forsake.mass. bawnssr. l building orimprovemat4hathwithinaneyear of capeave fr Napuaof lox:.). wi8 haw the bueden of proving Out he did ata ddW a Improve fa purpve of ale.I. ❑1.as owner of the progeny am exclusively cwuactin{with limned wnmaom at construct the pmjea(Sec.70x4,Business am Proration Code:)M Contractors U. mass Law does not pply m an owner of property who builds or improv thereto.sed who contacts for such projects with a conuacwr(s)licensed pursuant m the Contractors Luense Law. Q lnmexemptundecsec. ,B{:PCfortbisreaon toner Dan WORKER'S COMPENSATION DECLARATION I thereby affirm under panslty,of perjury ons of me fallowing daclaatians: ❑I haw and will mainuinaCenlOesmof Cansentmulf-insumforWoftesCompen- sation,as provided for by Section 3700 or he Labor COM,for me performance of Ons work for which this permit is issued. ❑1 have and will maintain Worker's Compensation Insurance,as reyvirtd by Section 3700 of the Labor Cole.for the performance of the work farwhich this permit is issued. My Worker's Compensation Insurance artie�r and Policy number are: Carol,. ?u,94 e- Al 61 flc No.:VjG_?P3?3 A7^ CERTIFICATE OF FXEMP ION FROM WORKERS' COMPENSATION INSURANCE This salon wed not becompuud If the permit is forone hundred dollas(S100) or les..) 1 certify that in the performance of dm work for which this permit is issued,I Nall not employ any person in hay maeerha as to become subject to IM Workers'Compensation laws of California Dau Applica s NOTICE TO APPLICANT.If,after making this OalOcau of Exemption.you should become subject m the Worker's Compensation provision of the Labor Cade,you a" .J O forthwith comply with each Provision or this permit mall W domed revoked z CONSMUC`nON LENDING AGENCY gI hemby.Rom that mart I.a contractors,lending at faux pmEmmace of > than wok fa which this permit is issued(San.3097,Civ.C.) D3 Q Landers Naas az LendersAddren U O 1 certify un 1 haw mad this application and sum that thc abase information is Ly room I agree to comply vim all city ad county onlinutas ad mute laws mbting m O SV": building construction,ad hereby unhorice representatives of this city to unity upon me W abavomentioned pmpcny for lupacUan puupoes (We)agree to use,Indemnify ad keep armlet the City of Cupertino spial ti IAA liabilities,judgments,costs ad expenses which may in ay way imine agatnst said City fJZ in consequence of the granting of this permit. s"s APPLICANT UNDERSTANDS AND W OMPLY WITH ALL NON-POINT Issued by: Date SOURCE REGULATI Re-roofs Signature ppllesHAZAR O Us HAZARDOUS MATER AIS DISCLOSURE Type of Roof Will the applicant or fumm building occupant mom a handle hmallo s manurial u defined by IM Cupertino Municipal Code.Chapter 9.12,ad the Health ad Safety Code.Section 25532(4)7 d.11/ All roofs shall be inspected prior to any roofing material being installed. ❑Yea Will tier applicant or(atom building occupant esu equipment no devices which If a roof is installed without first obtaining an inspection,I agree to remove cmlt hauNnus Air conumina m u dcfincd by the Bay Area Air Quality Management all new materials for inspection. Distrid7 Q YostO I haw mad the aardan makerialsmammumcnu under Chapter G95 ofue Califor- nut Heat"SafcyCade.Seedau 25505.25533 25534.I understood thmifdw building dm cel currently he.•moat,esu It is SpOrsponsibility m wdfy dm occupant of the requimmen0 which muss w met pd i anon CcniOnmar posy. Signature of Applicant Date owners man as at 8 1 o m All roof coverings to be Class"B"or better G