05030321 CITY OF CUPERTINOs� c»etxmm',EY.S
BUILDING DIVISION PERMIT CONTRACTQR INF RMATION`*
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO.05030321
OWNER'S NAME: PERMIT ISSUE DATE
E: SANITARY NO. CONTROL NO.
38 Q 171
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ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDGO ELECT l� PLUMB MECH
O O
�OO LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm duel I are licensed under proWo
v
ans of Chapter 9(commencing
with Section 7010)of Division 3 of de limmossand Professions Code.and my license is
n in full force and effect
Lkense Cl Lic _`{96/ 03/ NEW CONDOMINIUM
F� Doge C.mmcmrL_�F O-C) 1349 SQ. FT. LIVING
0 Q ARCHITECTS DECLARATION
ryJ I understand my plan shall M wed as public mcnrw
ito. Licensed Professional
Oat I am exempt
from
DECLARATION
E0 0 I hereby a1Rm that 11. wempt from Ne Consorts Co :Any C taw for the
ipo which re roman, erte(Section 7031.5.Business and ve,dcnmi Code:Any oily vercounty
$_ whichitsisssae.alsareonres thealter.ImPmve,deermitt or repair siny gned statement prior mits iensedp,alta requires the applicant for such Permittoice ssignedmatem,nt N160
p= < tiomingokcnsedpurauam10 the 70M)provisionofNeCommmur'aLicenceLaw(Chapger9 Sq.Ft.Floor Area Val�j3],i
C $ that he rte exempt
Section70M)of Division for
of the Business and professions Anyavi Cade)or
.. Utas he u emmpt lMaefrom and the baso(o de alleged exemption.Any Halation of
Section 7031.5 by any applicant for a permit subjects W applicant to a civil Penally of APN Number Occupancy Type
OW more Nen Ove hundred dolls.(5300).
36940002 . 00
C)Lae owner of due pmpmy,or my employees wldu mgu n their mle compenniim.
will do the work and the soommm is notinuMoxim.ffered forsale(Sec.70a,Businrn Required Inspections
and Profession Code:The Cowaemr's License Law does of apply m e ns an swam of q P
propenywho buildsoimprov deomm.end who doessuch work himmifver Uu uagh his
own employees,Provided that such Improvements art of intended or offered for sale.IL
however.the building or improvement is mid within mm)w of completion.the owucry
builder will have the bund,.of proving Net bo did nor build or Improve for purpom of
ale.).
O 1.as owner of the propeny,am exclusively contracting with licensed contractors to
ceramics the preecs(Sm 70114,Business and Prowasims Cade:)The Ct mracmh U.
cmue law docs vol apply m an owner of property who builds or improv dereon.and,
who canuacu for such projects with a commctor(s)licensed pursuant to the Contrmmh
License Law.
❑1 am exempt under Sec. .B k P C for this reason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hemby afRrm under penalty of perjuryone of the folmwing declmdow:
❑1 haw and will maintain a Certificate ofConsenl m sciNasum for Worker's Compete
action,as provided for by Section 3700 of the Labor Code.far Ne porfarmmce of the
work for which this permit is issued.
0 1 have ad will maintain Worker's Compensation Insurance.as required by Section
3700 of the Labor Cade,for the performance of the wart for which this permit is iaued.
My Worker's Compensation Insurance tinier and Policy number am:
Caner:'Z(/I40f-A-f"YCA-✓ Pallay Na,;we 3s33/o3-�
CERTIFICATE OF FXEMP iON FROM WORKERS'
COMPENSATION INSURANCE
mw section recd stet aocampleged if Ne permit is for.hundred doll.(SIM)
or less.)
1 certify that in the performance of the work for which thio permit is iaod,1 shell not
employ any person In any mannerm as to become subject to the Workcts'Compenatlon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after making this CedlOote of Exemption,you shoed
became abject m the Worker's Compensation provision of the tabor Code,you mon
OZ foMwith comply with such provision or this permit shall bo deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
[-t IWader art,.vias there is a conmructina lending agemT for tie perfmmacce of
fY> tM work for which this Permit Is Issued(Sec.3097.Civ C.)
W Q Lender's Name ,
G sander's Address
VQ 1 cenify that I have read this application and stage that the above Information is
LF correct.I agree m comply with all city and coldly ordinances and stag laws relating in
O building construction,and hereby authotim eprestnudw of this ity as enter upon the
tgl above-m,ntianed pmpeny far impection purposes.
(We)agree as ase.indemnify and keep harmless Ne City of Cupertino against
L41 IlabiliUes.judgments,caw and expenses which may in my my mems against aid City
V 7 in consequence of to gamling of this permit.
•^^ APPLICANT UNDERSTAND D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGUL TIONS,
-22�
e�: Re-roofs
Signw AppliesndContracdo Dae
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant atom orhendlc heardous material
as defined by the Cupertino Municipal Code,Chapter 9.12,and the Health and Safety
Cabo,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes Bflu
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
am][hangings air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection.
District
❑Yes u
I h ave mad the hamtdtms mwrlal s requirements under Chapter 6.95 of Ue CaliBur.
nia Health@Safety Code,Sd-u=25305 533aa125534.lundcrswWgmiNk building
data not curtcntly have a tenant.Nat s my responsibility ec notify Oe occupant of the
requirements which mum be me ' r sswnccafaCerti0cageof Occpany./ Signature of Applicant Date
O
6511;11 All roof coverings to be Class"B"or better
wns n autho sed•gem .01 DEW
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