05030320 (2) CITY OF CUPERTINO .m ' *ar^r .?
BUILDING DIVISION PERMIT C01vTItACTOR NF'TORMATI 1 �x
BUILDING.ADDRESS: W E O'NEIL CONSTRUCTION PERMITNO05030320
OWNER'S NAME: PERMITISSUEDATE
2005
'EMNE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG EO PLO l�
�86 LICENSED CONTRACTOR'S DECLARATION Job Description
1 hereby affirm Net 1 am licensed under provisions of Chapter 9(commencing
with Sector,70M)of DiMdun 3 of the Bad.rod Prefussiom Code,and my license is
a't InfunmLre}eWandefra (j (,f 1U Qyf NEW CONDOMINIUM
��Z Lice TT con
✓
3 dem fe r 1349 SQ. FT. LIVING
ARCHITECTS
DECLARATION ARATION
1 understand my plane,hell bo used u Muhlk records
3`� Lkenud Professional
OWNER-BUILDER DECLARATION
E D O 1 moods affirm o n I am exempt from the Cssion o License Law co nm
O o which
moon.(Satin 7(131.5, t,Business and Rafadum Code:My my m county
$ which requires,.,rill re car s the apes.W prow,h permit
or repair any structure
FZf:'
prior miu ienence,alsumgothe lW applicant o for ash Permi's N.Law(Chapter
{qzFpD Na me IicemedMSeaaUofe,ofDiaiomofthe the
Lice law(Clodmr9 Sq.Ft.Floor Area Val$&56160
6 3$ than a Is
(commencing pt therefrion om
and
the basis
3 of Nc alleged
and Proon.Any vi Code)or
3
that he h exempt therefrom and Ole buts for Ne alleged exempllon.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicanno a civil penalty of APN Number Occupancy Type
not mom Nen five hundred dollen($500). 36940002 , 0 0
0 1,as owner offt property,or my amploy,m with wage,u Neiredle compensation,
will do the work and the suumure is not intended oroffetad frrWe(Sec.7011,Business Required Inspections
and Prefesaiom Cc&The Common,Liter, Law does mot apply m a ounce,of ns of q P
property who Wild c,hardens thereon,and who doeaauch weeks himvlforthrouth his
awn employers,provided that such improvements are not Intended oroRemd for side.IL
however,the building or improvement is within one year of completion.the owner
Wilder will haw door burden of proving that M did not Wild m impede for purpose of
ala.),
❑1,a owner of the Property am exclusively contracting with licensed conuacurs to
constmct the project(Sec.7014.Business and Profession Code:)The,Co muter'.Li-
cence taw does not apply to an owner of property who Wilds or imProwa thereon.and.
who eonleama for such projects with acontracmrts)licensed pursuant to the ContMo ,
License taw.
[3I am exempt under Sea ,B k PC for this wan
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declanuaa:
❑I ban and will maintain a Cenifiateof Cogent to elf-loom fo Worker'sCompen-
ation.a Provided for by Section 37M of the labor Code.for to performance of the
mark for which this pend is issued.
❑1 haw and will maintain Worker's Compensation Insurance,u required by Section
3700 of Ne Labor Code,for the performance of the wok for which this po unk le issued.
My Worker's Compensation Insurantt artier and Policy number see:
Carder:2ul yCN-A^7 et4f/R�Policy No.:y6YS-33/e 3--d
CERTIFICATE OF EXEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(fhh anion need rot W cmnplcmd lite permit Is forone hundred dollar,(3100)
or leu.)
1 certify that in the performance of the work for which this Permit is hand.I shall not
employ any Nixon in my manner sat u an become subject to the Workers'Co rd cm adon
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Cenincee of Exemption,you should
become subject in the Worker,Compensation prowlsona of Na Labor Code,you mum
OZ fonhwith comply wife such provisiam or this permit Nall W doomed revoked.
,zvCONSTRUCTION LENDING AGENCY
`
[••r (hereby airum that ft.isacenmmcWm lending agency for the lerfumumc of
!Yi> the work for whim this permit is issued(Sec.3097,Civ.C.) .
QLanders Name
z Lender',Addw
f)Q 1 certify that 1 ban mad this application and,tam that the above information Is
{s.!'. coni.I agree to comply with all city and county ordinances and sum laws misting N
OkSJ� building conduction.and hereby,authentic mpwntatiwaofthis city in enter Upon f
W show-mentioned property,far Inspection purposes.
(We)agree in an.indemnify W keep harmless fee City of Cupertino agaimt
.w TSO liabilities,Judgments,toms and expenses which may In anyway carne against Said City
U 7 in consequence of the Stenting of this Perm,.
A APPLICANT UNDERSTANDS A LL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
7-
2211 3 Re-roofs
8 2 9�
Signa eafApplirmVC.h=to,
HAZARDOUS MOERIALS DISCLOSURE Type of Roof
Will tip applicam or future Wilding use.pat stare ser handle haandous maedn
u defined by the Cupertino Municipal Code.Chapter 9.17,and the Health and Safety
Cam.Section 255324)? All roofs shall be inspected prior to any roofing material being installed.
[:]Y. ETND
WIII the applicat or future be idin oceap.nI as equipmer,t ser devices whim If a roof is installed without first obtaining an inspection,I agree to remove
emit huardnus elrconnminan as do f by tea Bay Area Air Quality Managcm,ni all new materials for inspection.
District?
0 Yes u
I have mad the haarNms mamdals requ lremenu under LTap k,6.95 of the Cali fan
niailallhk SafctyCodc,SccWm25505.O5S�end23574.1 uMctmandthmll"'Wilding
does ant cuocndy haw a meal Na 0,h nsporuibillly m nod IT tho=owl of Ne
requirements which mum bi melpdor/ s cea(a CcrtOcate of tic trParmy. Signature of Applicant Date
>�`W195— All roof coverings to be Class "B"or better
Owner or auth dyad ensat0 m
C1_