05030268 (2) CITY OF CUPERTINO s o- >++ ^-f� p`p'
BUILDING DIVISION PERMIT kCONsRACTOR4NFORMeATION
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION "I'll ND05030268
OWNER'S NAME; PERMrr ISSUE DATE
2005
E: SANITARY NO. CONTROL NO.
510) 385-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT P0 LUMB 0MECH
0
B86 LICENSED CONTRACTOR'S DECLARATION Job Description 1 hcmby Af em that I am licensed under provisions of Chapter 9(commencing
Ith Section 1000)of Division 3 of the Business and Professions Code,and my linen¢is
infuRmmeandefrom. �ay Oaf NEW CONDOMINIUM
L E Datanse Claes ConLlctracter 1.d C; N -T
1193 SQ. FT. LIVING AREA
ARCHIT3 Q ns mail
DECLARATION
blicmet&
Jy 1 understand my pins NJI be tired a public rtenrN
3
.`sad
Licensed Professional
^ OWNER-BUILDER DECLARATION
3< I Winter Maso affbm that 11. exempt from the Contractor's License Law for the
p o fallowing mason.(Section 71131.5,construct,alun, and vc.dem ns Code:Any city m county
tme
$ which rtqutrcs n Permit m iMAthalter,hnPmw,demolish.,nr mash any tatemum
F S^ Pdar m its Issuance,mu rc in ban the Applicant far such Permit as Lie se Law statement
F�< that heb!nSwiL pursuantmOmprovisiooaf Contractor's Pmclaw(ChaPurY Sq.Ft. Floor Area Ya a1t1'b6101
(comm Well xem ith Section 70ndsh basis n3 oaths Busineamton.Myovi Code)of
Out Well exempt timrcfmm and Un baso fm the alleged exemption.MY violators of
Section 7031.5 by any Applicant fm a Permit subjects do spillkmt to a civil penalty of APN Number Occupancy Type
ant team than five hundred dollen($500). 36940002 . 00
❑L As owner of the property,a my employees with wages As Neirsole compenatka,
wiildadice,"kandthe mM
ucmrc b not intended araQered formic(Sec.7044,Business Required Inspections
And Pmfasslom Code:The Comor's License Law dean not apply in an ns an owner of q P
pmpm y w ho bui Ida or imprmn daemon,and who dm..such wart himself ser through his
aunt employma,provided dot such Improvements are rot intended mortared forale.If, -
howevu,the building m Improvement is sold within arc year of completion,the awrcr-
builder .w0l have the burden of proving that he did tet mild or improve fm purpose of
ale.).
❑1.as owner of Ne property am exclusively contracting with licensed contractors to
construct the project(Sec.7014.Boatmen and Profession,Code:)The Camrecurs Li-
cense Law does not apply Man ownm of property who build.or improves demon.and,
who comma"for such patinae,with amnusctm(.)licensed pursuant in the Gntrutors
Luense law.
❑I am exempt new Sec .B&PC far this won
Owner Data
WORKER'S COMPENSATION DECLARATION
I hcmby amrm under penalty of perjury am of the following declaration,:
❑Ihswand will main W..Cmifateof C...tuaself-WumfmWortursCompers-
atlon,uprovided fm by Seetian 3700 of the labor Code.fm tiro perfonnemx of rite
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,As required by Section
1 of the labor Cade,for the performance of the work for which this permit is issued.
My Workers Compensation Insurance write ad Policy number ate:
Cartier. Z lkiCte As't iicy No.: 3.'C'?3 AJVr
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(lab section bond not bo complewd If the Permit is froom hundred milace($100)
m tea.)
I certify that In the perforromam of the work per which this Permit Is luted.I shall not
employ any person in any mmmr an As w become subject to thaWorkera''Compensedon
Laws of Cuifoaia.Date
Applicant
NOTICE TO APPLICANT`.IL after making Nb Certificate of Eacmplion,you Would
become soblact in the Wo&ars Compensation provbions of the Labor Cad%you muss
.J O roMwith comply with such provisions or this permit Wall bo deemed rcwkcd.
v~y.. CONSTRUCTION LENDING AGENCY
'(•v I hereby Affirm Out then is construction lending agency for the Performance of
Ri> the work for which this permit b Wood(Sec,3001.Civ.C.)
4 Q Landers Num
L.z Lender'sAddeass
U0 1 modify that 1 have read this application and sum that the above information b
W, ^. rosemas ca.l agree to comply with all city and county ordinand mm laws relating m
0 rV^ building convection,and hereby authadae representatives of this city in curer upon the
W above-mentioned property for inspection purposes.
gyr (Wc)agree to ave,Indemnify and keep harmless the City of Cupertino against
r Vl liabilities,judgmcau,cents ad expenses which may in my way accrue against said City
V',j„' Inconsegamceofthcgrantingafmis m,iL
^� APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR REGULATIONS. 'V' 24 14f
Re-roofs
�Ignuurc pplicanVCan=wr Data
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or forum building occupant nom orbandlc haurdous material
As de0rcd by dm Cupertino Municipal Code.Chapter 9.11.and the Health and Safety
Cam.Secure 25531(0)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes ICU
Will the applicant or fuwm building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
telt hmardam all conuminann As del by Ne Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes u
1 havered Ne hmndms meurlebrcquiremenLLmderChaptari95 of the Glifory
nu Nnith&S.r IyCo ,Scmmr15M5.15533u 25534.1undereuM thnifthc building
does tetcurenuy haw A usam,that bei my acpon,iNiiy at notify the mcurem ofd.
requirements whwh_ich muss Wmet Tri nuatmcara GolGcata of Ox Parry. Signature of Applicant Date
Owncru"r aull�arizcde cm 0.,3 w^ All roof coverings to be Class°$°Or better
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