05030247 CITY OF CUPERTINOxr. nW � FsY7s %ter
BUILDING DIVISION PERMIT CONTRtJIC,TQR INFURMATTAN t.,
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMITNo.05030247
500 TOWN CENTER LN ft 181
R'S NAME: PERMIT ISSUE DATE
IV
SIVLERSTONE DEVELOPMENT 5245 PACIFIC
PHONE: SANITARY N0, CONTROL NO.
(510) 385-0121
BUILDWO PERMIT INFO
ARCHITECT/ENGINEER:
' BLDG ELECT IS t� PLUMB MECH
D t�
igg LICENSED CONTRACTOR'S DECLARATION Job Description
j)y I hereby arprm that 1 am Iimmed under provisimu of Chapter 9(cnmmenring
with Section 7W0)of Division 3 ofthe Business end Professions Code.and my licamse is
In fun forcemdaffect NEW CONDOMINIUM
n 2 Lic<nm CIO
l LIc.M N'1�1 e 3
Dam Contnewe L/C NE/1 743 SQ. FT. LIVING SPACE
ARCHITECTS DECLARATION
I moderated ted my ph.shall o dead u public re tench
liO� Licensed Professional
OWNER-BUILDER DECLARATION
nygy 1 hereby IMM that i am exempt from the Contractors License Law for the
`G O following moon.(Section 7fill.S,Bum.and Pmfeealotu Code:My city or county
5$ which requires a Permit to construct.altar,Improve.demolish.or repair my structure
-4- prior it,its iwmna.almrcquircsthe applicantfor such permit tofileaalgnedmammmi Valu$66009
< dutheis licensed ressuantto the provisionaofthcCantrantu'sllaneLaw(Chapter 9 Sq.Ft. Floor Area
E (commencing with Section 1000)of Division 3 of the Business;and Profmians Code)of
3..
that he is eaccept taamfrom and the huh fm the alleged axempOm.My violation of
Section 703 1.3 by my applicant for a pemtfsubjects the applicant to a moil penalty of APN Number Occupancy Type
not mom than five hundred dollars($500). 36940002 . 00
❑I,uawrer of the pmpesry,m my empiaym withvegu u their role compemdm,
will do Newark,and the usucture Is not intended ver offered foram:(Sec.7011,But= Required Inspections
and Professions n sions Code:The Commutes License law donot apply m an owner of q P
property who builds a r improves thercon,end who does such work himself or through his
own employees,provided that such lmproaments arc notinunded or offered for sale.IL
however.in.building or Improvement Is sold within oro year of(mmpleuon,the owner- _
builder will have the burden of proving that he did not build or improve for purpose of
ale.).
❑1.as owner of the Property.am exclusively connecting with licensed mneracton m
construct the preject(Sec.70".Business and Profusions Cade:)The CmbacmYs Li-
cense law does not appy he an owner of property who builds or improves Neuron,and,
who contracts for such projects with a contsmmr(O licensed pursuant as the Conuactia"
License Law.
❑l am caempt under Sec. ,B A P C for this Kamm
Data
WORKERS COMPENSATION DECLARATION
1 hereby Olin under penalty of perjury one of the following deciaratlons:
❑I ham and will malnuin•CeNnmmof Conant m uif-inum forWarkeelCompen-
worm, r which this
fPe mi Salm 3700 a(the labor Code.for tie peslannma of the
weak for which Nia Permit is issued. ,
❑1 have and will maintain Worker's Compensation Insurio a,As required by Section
3700 of tie labor Code,fm the performance of the work for which this permit Is Issued.
My Workefs Compeumen lasomm a car�riera soul Policy number me:
Cemcr.,5Ll31(/LN'AA'IL /"+'Policy No.: f✓L3r33JeAt-
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Mhsemimn n,W ant be completed if tis Permit is for one hundred dollen(SIM)
or less.)
I unify that in the performance of the work for which this permit Is issued.I shall not
employ any person In my manmr to u to become mbject to the Workeei Compcnudim .
Laws of Califomia.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,You should
become suhjem in the Wohees Compircodon previsions of the Labor Code.you must
OZ forthwith comply with each provisions or this permit shall be domed em nked.
,Z,vO CONSTRUCTION LENDING AGENCY
[.., I hereby sirloin that Nem is construction lending agency for the perfmmmon of
C> the work for which this permit Is Issued(Sec.3097.Civ.C.)
{T] Lender's Name
0.z Panders Adan.,
V 0 1 cenffy that I have nod this application and sum that the thin infomudon Is
LL E~' comet.l agree m comply with all city and county ordinances and some laws hitting m
�w V building co)agccin,an.indemnify
eprm homeless
the
ty Of toenter
on against
F.t W move-mentioned property for inspection purpose,
G (We)ammo s,sea.indemnify and hap y I the City of Cupenim against
y It Wilioru,Judgmenu,emu and examines which may in anY waY eceroe against said City
C.1 in APPLICANTeof the UNDERSTANDSof this Perm 1.D WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUL TIONS.
8&,e C Re-roofs
Signmiticlif App i Hti
AZARDOUS PALS DISCLOSURE Units Type of Roof
Will the appilant or future Wilding occupant atom m handle hawNau material
0ned by the CupeNm Municipal Code.Chapter 9.11.and the Health and Safety
.section 35532007 All roofs shall be inspected prior to any roofing material being installed.
❑Yes ZJS
Will the,applicant or future Wilding oaeupant sec equipment or dcvim which If a roof is installed without first obtaining an inspection,I agree to remove
emit housrdnn air cmuminanu u defined by the Bay Arta Air Quality Management all new materials for inspection.
Dni,ict7 1
❑Yes gsd++
I has mad the hawrdous materials requirements under Chapter 695 of the Califon
nia FkalthBSafetycah.srcunu 1350s.25sJ3 531.IUMeround that if the building
does not currently hoe a tempt Net it h my ponsibilitY on
otify Nc eaupant of the
requirements which mum met prior afacertlncateaf Occup cy. Signature of Applicant Date
All roof coverings to be Class"B"or better
Owner ver mired gem Dam
L