05060212 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTQR INF'ORMA
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT 110.05060212
109.A9 PARK rRRRN IN
OWNER'S NAME: PERMITISSUBDATB
SILVERSTONE DEVELOPMENT 5245 PACIFIC CQNI7Q11RL�E, DE UP ng/�).9/2pnr;
E: SANTIARY NO. CONTROL NO.
(510) 385-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BO EQ PLUMB MICH
O
I00 LICENSED CONTRACTOR'S DECLARATION Job Descri tion
(y 1 hereby million Nal I M licensed under provisions of Chapter 9(commencing P
With Sudan 70(*)ofDivialon 3 of NO Burineaand Profhadens Code,and my license Is
n�z infulAnd effect. Lle9U o3� 2 STORY TOWNHOME 1441 '
Dau tic., for WW 6 F�
3 ARCHITECTS DECLARATION
I understand my Plans shall k osed u public meads
y
4 c�a Licensed Professional
3 OWNER-BUILDER DECLARATION
I hereby aRrm Nal I am ucmpl from tiro Canoenoe.Lieenm Law far the
o O following mason.(Secdoo 7031!,Business and Professions Code:My city or county
$ which mquima a permit to construct.alms improve,demolish,Or repair any etrucure $166810
prior m its iasuana.also requires Ne applicant forsuch Permit M file asigned Minimum
gg <
that kislicensed panuantncthe provisions nfMeCamrsemr'SLiecame Law(Chapter 9 Sq.Ft. Floor Area Valuation
Y�th (commencing with Section 7000)or Division 3 of ler Business and Proeslam Came)or
egg that he is exempt therefrom and Ne basis fm the alleged exemption.My vio4tion of
Section 7031.5 by any applicant for a permit subjects the applicant in civil penalty or Occupancy Type
oat mom then five hundred dollars($500).
❑Lasowner of"Property,army employees with wages as duirsale conpemadon,
windathew9rk,anditmclumm MlIntended IXarfemdfmY (See.7044,BusiMaa
Add Prefeasiom Cade:The Commences Liaise law does and apply in an owner of Required Inspections
property who buildsverimpno nMarcon,and whodocsouch workhimstlfm through his
own employees,provided that such improvements are not intended oroRered fersam.If.
however,the building or improvement la held within on year of complcuon,the owner.
Wilder Mn have the Woman of proving that k did rot Wild or Improve far purpose of
Ad..)
.
❑1.a owner of the property,am exclusively contracting with licensed conmcros to
construct the project(Sec.7044,Business and Profession Cade:)The Conmaor'a Li-
cense Law does not apply in an owner of property who bullas or improve Memon,and,
who contreta for such pmjecu with a conmmor(s)licensed pursuant mdse Canu.cter's
Licame law.
❑1 am ewmpl under Sec. .B d P C fm this Mason
wee Dau
WORKER'S COMPENSATION DECLARATION
1 hereby arfnm member penalty of perjury ane of doe following declaMom:
❑I have and will maintain a CeAflnse of Consent to self-Isom for Worker's Compen-
sation,u provided for by Section 3700 of the Inbar Code,for the performance of the
work for which this permit Is issued.
❑1 have and will maintain Workers Compemition Insurance.as required by Section
3700 of the Labor Code,for the perfamurcear the wok fmwhich this Permit is isseed.
My Workers Compensation Insur�a,ndce carrier and Policy number sm:
Carrier:'tiVit IGH -/I^841444.0,No.: 4/6 363 3/0 3—0
CERTIFICATE OF EXEMPITON FROM WORKERS'
COMPENSATION INSURANCE
('fhb sect m need an,be compicued If de permit b fm one hmmod dolum(S IDD)
or leas)
1 certify that In Me performance of Me work for which this permit is issued.I shall not
employ any Person In soy manner an as re become subject in the Worker'Compensation
Laws of Caiiforma.Data
Applicant
NOTICE TO APPUCANT.IL alum making this Cerincere of Exemption,you Mould
become subject to the Worket's Compensadan Provisions of Me Labor Code,you must
.7 Z forthwith comply with such provisions lir this pencil shall he decreed revaked.
Z O CONSMUCTION LENDING AGENCY
F-r I hereby M.that Mem is a amtmedm leading agency fo the performance or
tLv 7 the work for which this permit b issued(Sec.3097,CO.C.)
W�Q Landers Name
7Z
Landau's Address
U Q 1 certify that 1 hove read Uds application and sum But the show,information is
1,r'. cotreel.1 agree to comply with all city and county ordinances nd sum law muting to
Q building construction,and hereby authorize reprexma0vn of Mis city re cmcr upon Mac
W. .hove-mentioned property for Inspection purposes
yr (We)agree to taw.indemnify and keep hamrkss the City of Cupertino against
y liabilities,judgments.casts and expe•.^mi which may in any way accrue against Maid City
U incomomMic ofthe gramingof this permit.
F7 APPLICANT UNDERSTANDS 4W WILL COMPLY WITH ALL NON-POINT Issued by:qjtQ� Date
SOURCE REGULATIONS.
i ��.1 5— Re-roofs
Sign fApplicat Conmelor am
HAZARDOUS MORALS DISCLOSURE Type of Roof
Wdl Me applicant or future Wilding occeepent atom At handle harallous material
as defined by Me Cupertino Municipal Code.Chapter 9.12.and Me Health and Safety
Cade,Section 25532(a)7All roofs shall be inspected prior to any roofing material being installed.
❑Y3 [y vu
WIII MC applicant m Name building emupaet men equipment or dcvta3 which If a roof is installed without first obtaining an inspection,I agree to remove
emir ha undo air cmumlmnu as defined by Me Bay Am.Air Quality Management all new materials for inspection.
District?
❑Yes
1 haw mad the hvedmsmaterials mquimmentsunderChxpter6.93 of dm Califon
lib HmW ASafetycode,Seetioas 25303 25533 aad25534.l undcrrzW Mat ifdu building
don rot curmmly how a rent,th ( my mapomihllity nc notify thc occupant of Mc
mgoim emvwhichm lkmetp oissuaneo.r.c.ilnnniofoccPancg Signature of Applicant Date
fl�29�oS All roof coverings to be Class"B"or better
Owners hori'rsd agent — .�