05030255 CITY OF CUPERTINO * ' -'
BUILDING DIVISION PERMIT CONTRACTnR IN `f)1 Mr Tt ,N•
BUILDING ADDRESS: WME O'NEIL CONSTRUCTION PERMITNO'05030255
0500 TOWN CENTER LN #_27
IFEWS NAME: PERMIT ISSUE DATE
SIVLERSTONE DEVELOPMENT 5245 PACIFIC CON CURSE DRIVE 08/29/2005
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG eLecr PLO O
30z, . LICENSED CONTRACTOR'S DECLARATION Job Description
U 1 hcrcby affirm that 1 am licensed under previsions of Chapter 9(commencing
.¢ with Section 70110)ufDivlsien 3 of the Business and Professions Code,and my license is
< Io fell forceudeffeeLNEW CONDOMINIUM
�0z uansec.aa Lm.« N9y 03 /
Dam con= r wo D, elL, 743 SQ. FT. LIVING SPACE
ARCHITECTS DECLARATION
1 undersand my plans shall he used as public records
sQ Licenced professional
OWNER-BUILDER DECLARATION
.� I hereby.(Sere that 1 am1. exempt from the Conveners e:A nee Lew for the
Loo which
moon.permit
t ](131.5.Business and Improve,
d aiodi Code:Any city or county
3$� which require a permit m cnnslrucL alter.Improve,demolish.or repair any structure
-zy priorm its issuance,also require the applicant forsuch peest to file a signed miament
Nal he is licensed pursuant to the provisima of me Contractor's License Law(Chapmr 9 Sq.FL Floor Area Valu$06 0 0 9
$ (commencing with Section 7000)of Division 3 of Ne Businessand Professions Cods)or
Met the is
me basis
r Ma
olmi
on of
Section 70315 by any applicant for a Permit subjects Ne applicant to a civil(penalty of
not more man five hundred dollars($500). 9 4 Number Occupancy Type
366 940002 . 00
❑i,asownerwor of the property,r is employees with wages or their sem compensation,
will do thewons end Ne he Com Sonet intendedorLaw ed does formic(Sec.7044,Business
Of Required Inspections
and property
who
Code:The Contmcmr's Licence Law does not apply lf r t owner is q P
property whe builds or improves thereon,end who does s nth work himselfor Ms
awn employees,provided Net vemimprovements am netimmmdetl m offered tion.forsdethe Ow.r-
however,Ne building or improvement is hatd within oro you or improve
completion.me awe of
builder will have the burden of proving that he did not build or Improve far purpose of
tile.).
❑I,as Owner of Me property,am=elusively contracting with licensed contractors to
comuuct the project(Sec.7044,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who builds or improves themon,and
who contracts for such projects with a eontracmr(s)licensed pursuant to the Contractors
License Law.
l am exempt under Sea ,B&P C fmthis moon
r Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury..of the following dedaralmos:
1 have and will maintain a CeNficam ofcom unto self.insum for Worker's Compen.
sation,as provided for by Section 37M of Ne Labor Code.for me performance of the
work for which this permit is iuoml.
❑I have and will maintain Wor'ker's Compensation Imuruce,as acquired by Schon
3700 of the Lab ti cedc,for the performance of dm were for which mita permit is issued.
My Workers Compensation Insurance canise and Policy number are:
cacicr.'?uAjLN-,J- cit/U4✓policy No.:112 63 -
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
fridssection need nothecompleted if uta permit Is forenchundred dollars(SIM)
or toss.)
I cenify that in the performance of the work for which this permit is issued.I mmll not
employ any pecan in any manner se as at become subject to7M Wofkers'Compensation
Laws of CaRfmnia.Dam -
Applicant
NOTICE TO APPLICANf:If.afm,making this Certificate of Exemption,you should
became subject in the Workers Compensation provisions of me Lahor Code.you mum
�Z foMwith comply with smh provisions or this permit shall be deemed revoked.
�Z.,,O CONSTRUC ION LENDING AGENCY
H 4 lhereby afarota'them ie a conmmctinn lending agency for the performance of
CL the work for which this premia Is issued(Sec.3097,Civ.C.)
Lit 0 Lender's Name
a zleader's Address
V Q 1 certify that 1 have mad oris application and aura that the elbow information is
ECO=L I agree to comply with all city and county ordinances and mute laws relating to
V building construction,and hereby authodm representatives of this city to enter upon the
W above-mentioned property for inspection purpeaes.
gy (We)agree to on,indemnify and keep harmless the City of Cupcnino agaimt
fq Iiabilitmajudgments,costs and expenses which may in any any seem,against said City
t.)7 incomsubonceofineganungof Nis it.
F7 APPLICANT UNDERSTANDS WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
4-.5— Re-roofs
Signor ApplicmVConlnetor Gaiter
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant more or handle haurdous materiel
,fined by the Cupertino Municipal Code,Chapter 9.12,and Om Health and Safety
Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Dyes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanar nus air centemmana M defined by me gay Area Air Quality Management all new materials for inspection.
District?
❑Yoe &
1 haw mad the hamrdmn materials requirements under Chapter 6.95 of the Califon
nla Health&Safety Calc,Sections 25505.25533 and 25534.1 undemud that if the building
data not currently haw a mnmL mm it is responsibility to notify the occupant of the
requirements which must be met prior ceOf a Ccnifcam of Dgeumanny. Signature of Applicant Date
8 ,0 r All roof coverings to be Class"B"or better
0wn amhorirlagent 0..