05030245 CITY OF CUPERTINO77
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BUILDING DIVISION PERMIT CONTRr1.CTOTi INFORMAT<.
ION,`<,
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BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO.05030245
R'S NAME: PERMIT ISSUE DATE
SIVLERSTONE DEVELOPMENT 5245 PAC 5
PHONE: SANITARY NO. CONTROL NO.
510) 385-0121
ARCHITEC IENOINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
pr
LICENSED COMEACTOWSDECLARATION Job Description
1�u 1 hmeby afOrm din 1 Rem licensed under provision of Chapter 9(commencing
IN Section 7")of Division 3 of me Business Real Professions Code,Real my license is
.� In t0 amemao ne" p NEW CONDOMINIUM
i Llcenu elan Lk.g 4 µ 3 I
1�-- Dem Contractor w c a, � 743 SQ. FT. LIVING SPACE
ARCHITECTS DECLARATION
I understand my plans shell W shad Re public records
be
Licensed Professional
OWNER-BUILDER DECLARATION
X I herebymoo aakm that 11. exempt from the Comment's Cat n:Anha Law for the
i O O fallowing moon.mannit t 7 construct,
Business and ProImprove.
demolish.
Cole:Any oily or county
5$
which reydrn g permit m cnutmcL elms Improro,demolish,ear e a sig any t structure
-xi
tprim hat he
its iuuanm,dwrtquitoo the applicant for such permit to LMaasignedsumment
p 0 MuheoingwitpursuauraWprorisiomo(thche usines'rUcenaclaw(Clupmr9 Sq.F[. Floor Area Valu 186009
y that he exempt
Section
m,andteIDivision 3 of thccu(nwmton.My
Cod e)of
Q�� Out k V aumpt tMac(rom and Um buss for the allcgc0 assumption.Any N.IW on of
Section 7031.7 by any applicant fon a permit subjects the applicant to a civil Pendry of APN Number Occupancy Type
Out more than five hundred doling,($5110)' 36940002 . 00
❑L u owns of Die property,ar mY ewin wgo u reek hat co 4.Bobso,
Will domewom and meswcimeumoeintended Licmen LA do r an,appl(Smy
ina4.Bualrcsf Required Inspections
and Property
who
ou Code The Conuervem. ndsme Law saes cot apply lf rt owrcr of q P
me ertywW Wiprovidmproroack imnaalwho thenouh work aroffecredmselfor fonugh his
own a however.
the
m improvement
Imps mid wait the not Intended moacrtd forW&e.merger.builder Ne bullringuimprovementishaltwithinoneyear ofImproefarme.wwer-
.iilecr will have the burden of proving mu W did not build or improv fn puryoha of
talc.).
❑1.as Owner of the property,am exclusively contracting win licensed cont actota m
comtrom the project(Sec.7044,Business and Profosiou Code:)The Camrsemes LI-
ceme law does not apply m in Owner of property who Wilds or Improves Oregon.and
who contracts fon such projects win a eamremor(s)licensed pursuant Re the Contrhamfs
License law.
❑I am exempt under See. B h P C for this mom.
Date
WORKERS COMPENSATION DECLARATION
I hereby Salem under penalty of perjury owe of the following deelaretome:
1 have and will malnuin aCertfiate of COnsunt to self-i...m forworYeYecompen.
Orion,Re provided for by Section 3700 of the Labor Coda,for me performance of the
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation hudg era,as required by Section
37M of the labor Code,for tW Performance of dre wok for which this permit is Issued.
My Worker's Compound.Insurance canner.0 Policy num W,tae:
Cmim,,—A_uLILN-A-V41C ncyNo.:6L63$3310 -
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
(nossumd.weed waloccompkmJ IHhe permit is rear one hundred doORers($I00)
or ins.)
1 certify that In to performance of the work for which this Permit u Moon,I shall nm
employ Reny person in any manwer ha u m become white[to me Wmkert'CompenuOOn
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If.after meting this Certificate of Exemption,you should
become subject m the Workers Compensation provisions of the labor Code,you most
O O faMwith comply with each provisions o this permit mall lose deemed revoked.
.Zan CONSTRUCTION LENDING AGENCY
[s IWmby affirm that mem is a cons0ucdon lending agency for the performance of
a> the work fon which mu permit is issued(Sce.3097.Civ,C.)
dQ Lender's Name
0 z leaches Adder..
U O 1 comfy that 1 have read this applicant..and sum mu the gave mformadun is
ly(~ cornet I agree m Comply with all city and county ordinances end mm laws muting m
0U building conswetion,end Wroby amhodn representatives of this city m enter upon the
` [77 shove-mentanedproperty forimnify a keep ha
le-^t a
(We)egttt m taro,indemnify and keep humleu me City of Cupertino against
rA Ilabilides,fudgmenu.eau ando,.which may in my way Renru against said City
U 7 In con¢qunce of me granting of mi permit.
F7 APPLICANT UNDERSTANDS D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS,
�i 3�z9 os Re-roofs
Slgnmu ApplicanUComracmr Net,
HAZARDOUS MATERIALS DISCLOSURE Type of Roof '
Will thc app iant or future building occupant stom or tialte be ardou Material
fined by the Cupo ma Municipal Code.Chapter 9A2.rad the Health and Safety
.
Sectio.25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yn (P"6
Will the applicant or future building Occupant me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmlt haordno air contaminants u chimed by the Bay AMR Air Quality Management all new materials for inspection,
District?
❑Yea
I herr read the haadous memriduequimmenuunderChapier6.95 orthe Califar.
nla Health&Safety Cndc,Sodom 25505,335334nd 25534.1 undcuand thuifthc building
dao not curenty hoc a mnanu th It's my mspoulbility m Imtil'y Om occupant of the
mqulmmanta whkh mug M mea o issuance Ora Ondfmaue or Occupancy. Signature of Applicant Date
Owner or oil><a agentDa All roof coverings to be Class"B"or better
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