05030271 CITY OF CUPERTINO "?' A' aag, _�' ' "' a'"'' - `
BUILDING DIVISION PERMIT CQNTRA6URINFOItMATION
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMITNo'05030271
2P500 TOWN CENTER LN ft 2R9
R'S NAME: PERMIT ISSUE DATE
SILVERSTONE DEVELOPMENT 5245 PACIF 08/29/2005
PHONE: SANITARY NO. CONTROL NO.
(510) 365-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
i00 LICENSED CONTRACTOR'S DECLARATION Job Description
sad I Iemby affirm Net 1 em limited under provisions of Chapter 9(commencing
with Section]IKID)of Division Sof We Business and Pro(cssians Conte.and my license is
infull(omeandeQeeL �N e-3 NEW CONDOMINIUM
Z License I Lic.N
Dam Camrmtor w ? 1193 SQ. FT. LIVING AREA
2 ARCHITECTS DECLARATION
1 understand my plana shall he used as public mcnrds
p
IO Licensed Professional
OarNEm BUILDER DECLARATION
AX I hereby e(Bnn Nat 11. exempt from the Gantrneror,License Lew for IM
O O following mason permit
t RD I.S,Business and Re,denvli Code:My city of county
S$ polar mquims•pmnit re cnnsuuc4 alar,improve,demuliN.ea repair any swam,
pilar
� marequires the applicant for Nemit m filo erWemnl
that he its
pursuant We provisions or he Commoner Limnse Law(Chaprer9 Sq.Ft. Floor Area Yal$
aL!®101
(commencing with Section 70D0)of Division 3 of the Business and Pollution,Code)or
that he is exempt IMmfrom and the basis for the alleged exemption.Any vlpmtian of
Section 7031.5 by any applimat for a permit subjects the applicant to•civil penalty of APN Number Occupancy Type
not more than fve hundred dollen(3501)1 36940002 . 00
❑1.u owner of ft pmpeny,m my empb)«a with wgu u N it Nle eompenndon,
willdu Wewok,enditlmmumisnotimendwmontn f-1 ele(Sec.10".Bwinw Required Inspections
and Professions Commutes ThCommutesre
rs Lieerm Law docs t apply to an owner of q P
Property who build,orimproves thereon.andwho doeaeuch werkhimsel(or Waugh his
own employ=,provided that such improvements me not intended moaered lotions.If.
however,We building or improvement is mid within out year of completion,the owner.
builder will haw the burden of proving Net he did not build or improve for purpose of
isle.).
0 1.as owner of the property,am exclusively contracting with licensed contractors Ice
common the prejm(Sec.70th.Business and Professional Cade:)The Contractor,U.
cove law dou oat apply m an owms of pmpeny who builds or Improves thereon,and,
who contracts for such projects with a contrecmrts)licensed pu mus,to ft Contractors
License Law.
❑Iamexemplumbu See ,B&PCfmthienamn
r Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of Lha following declarations: '
❑IhaveeM willmainWna Cutificate of Consemtoself-InsumlorWoker.Compen-
union,as provided for by Section 37(D of Lha Labor Code.far the performance of de
weak for which this permit is ismal
❑I have and will maintain Worker's Compensation brivence,as required by Section
37W of We labor Cade,for the peRormanm of the work for which this pomdl Is Issued.
My Wakes Compensation Ininrana carom and Policy number am:
Ca rier.'Rr ICH•A^elf(Lr9x11foliry,No.:11K 31 —6
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This motion med not beconpleed if tie permit Is(mane hundred dollars(SIM)
or less.)
1 coolly that In We performance of do work for which this permit is issued,l shall not
employ any person in any manner an as to become subject to the Workers Compensation
Laws of Ca)ir.n.n.Date
Applicant
NOTICE TO APPLICANT:If,after making this CcniOum of Exemption,you should
become subject to We WorWYs Compensation provisions of the labor Code,you must
0 for1wiW comply with inch provisions or this permh Mall he rimmed nvnkcd.
z CONSTRUCTION LENDING AGENCY
[••i I hereby affirm that Were iso convection lending agency for de perrurmenco of
C> de wok for which Win permitis issued(Sm.3097.Civ,C.)
W Q Lenders Name
2 Landers Address
f,Q 1 certify Wet i have read Ibis application and s e that the,bow inform W on is
LL C• corrcte .l agree In comply with all city toll county ordinances and sum laws missing In
Ot) building construction,and hereby NWoom relativism of this city to env upon the
W .hove-mentioned property for inspection purposes
gy (We)agree to saw.Indemnify and trcp loveless the City of Cupertino against
Co, liabilities judgments,cods and expenses which may In my way Ncrum against mid City
U 7 In consegmnee of the imnting of this permit.
tom— APPLICANT UNDERSTANDS AND 1 COMPLY WITH ALL NON-POINT Issued by: Date
SOURCERECULATIO S.
&fe0 z Re-roofs
Signa trconummr one
HA2.ARDOUSMATE ALS DISCLOSURE Type of Roof
Will de applicant or future building uccupanutow or handle historians material
fund by We Cupertino Municipal Code.Chapter 9.12.and the Health and Safety
40.Section 25532(.)7 �� All roofs shall be inspected prior to any roofing material being installed.
❑Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree t0 remove
emit hmardnw air contsmimnts as defined by Wo Bay Ana Air Quality Management all new materials for inspection.
District( /
❑Yen
1 have mad the berardousmaterials requirements under Chaper6.95 of the Cables.
nil HcalLh&Safcey Cadc,Smdom25505,25533od25534.1.dm WUlrthe building
dacenotcunendy hewa,nen.Netitisny pomlhilitymnotify Weemcupmtofthe
requirements which muR be mel prior man cerdRcam ora parer. Signature of Applicant Date
Owncr a Women agent 9 and All roof coverings to be Class"B"or better
e