05030277 CITY OF CUPERTINO "`?''S.laws-+ °ss"2'mrsk'"^'%v' 'v"'r"x°' '�" t''..
BUILDING DIVISION PERMIT CONTRACTOR NF,0RMATI0
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT N0.05030277
0500 TOWN CENTER LN # 178
R'S NAME: PERMIT ISSUE DATE
SILVERSTONE DEVELOPMENT 5245 PACIFIC CONC E DR VE 08/29/2005
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCH=IENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION Job Description
FFF{� 1 hereby affirm that de
at I am licensed unr provisions of Chapel 9(commencing
R with Section 70(D)of Division 3 of the Business ad Profession Cada,and my license Is
�y m Trot roses an de Bat. NEW CONDOMINIUM
n Z LlcenseClur Lk.0 1� 4th !9 3 1
�IIf�...' Dam conzaaw t✓ E art Eft 1116 SQ. FT. LIVING AREA
SQ ARCHITECTS DECLARATION
Jy I undcommd my plans shall he used an public rams,
yC
Licensed Profcuional
Oat I am exempt
from
DECLARATION
I I greeny aDbm that I em exempt from Ne fes ions Co License taw for the
o O following muoa(Section IlOId,Business and Improve.
durum Code:Any oily or aunty
5$� which mquiona•pannit m twtsuuct.elms Wpmw,nnmolbh,or repair any swmuro
_ij, prim m its issuance.also requires the applicam for such permit b Bk au
a sigmd mnal
F� thathe islleansed pumtantmdtepmvlsiounfthe Camracmr'a U..Law(Chaptor9 Sq.Ft. Floor Area Va a]t129188
$ (commencing with Section 7030)of Division 3 rite Businessland Profcuiau Cede)or
that he is exempt therefrom sod Ne basis for the alleged exemption.Any violation of
Secdon 7031.5 by any applicant for a permit subjects to applicant to a civil penalty of ppNN tuber Occupancy Type
not mom than five hundred dallam($.500). 3 6 9 4 002 . 00
❑I,moworrofthepropmy.mmyemploywawMth gesu0enmleoempenution,
will do Me marks.and Mestmmme boot mended urarteted mraam(Sea.7W.Business Required Inspections
and Professions Cade:The Conumn mes Us me law denot apply mean owner of q P
property who but Ids or tmpro am Merton,end who does such work homelier through his
own employee,provided thatsuch Improvements an afthm nded oroRered forule.if,
however,Ne building or Improvement is mid within am your of completion,Ne owner.
builder will have the Widen of proving that a did not Wild w Improve for purpose of
ask.).
❑I,u owner of the Property am ealusiwly cmusemi,with Iiamed mnuuton m
consumer to project(Sec.Trim.Business ad Profesaiotw Cade:)The commemfa U.
came law does rant apply no an owner of property who Wilds or improves thereon,and
who contracts foe such projects with a co t rsetm(U licensed passant to the Comalofs
License Law.
❑1 am mempt under Sec. .B e.P C far Nis mason
Duk
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury Coe of Ne following declarations:
❑I have and will maintain acerincam of coven to selFlnsum for Workers Cumpem
gotten,an provided for by Section 3700 of dee Labor Cade,for Ne perfunnam of me
work for which this permit is issoed.
0 1 have and will mainuin Workees Compensation Insurance,an required by Schon
3703 of the ubo,Conn,for the pafamrance arose work for which this permit is Issued.
My Warknes Compensation Imwance carrier and Policy number son:
Calm:VIAtcW-A,�00CA-6)licyNo.:wc.7r33/e?-oS
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
rihh secdon need notecotnpltted ifte Permit is fwane hundred dollars(5103)
or Wu)
1 arty Nat in Ne Performance of Ne work for which this Permit is issued,l Mail not
employ any psm an In any matter u an became subject to the Workers'Compemmon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:if,aper making this Ccaiftute of Exemption,you Maid
become subject mint Worker's Compensation provisions or me oboe Cade,you mm
.,z forthwith comply with such provision or this permit Nail a dtemtd revel cd.
zy CONSMUCiON LENDING AGENCY
[•+ I hereby affirm Nat Nem is construction lending agency for the perfarmmm of
ai 7 Ne walk for which this permit Is Issued(Sm.3097,Civ.C.)
GQ Lendces Namc
Z)z Landees Address
U O 1 ttNfy that I have reed this appikumn need me into Ne above mfwmadan Is
tarsen.l agree m comply with JI city and county ordimmes and mu law relating to
O Wilding construction.ad hereby authorize representatives of this city m entre upon the
E
W 0-1-men0nned propeny for inspection purposes.
(We)agree in sew,indemnify and keep hmmleu to City of Cupertino against
y Ilabilitiu,judgmenu,awxp
ta andeceses which may to my way seems agairm mid City
U 7 Ineonsegnmeaf Negrutingofthispeemil.
Fl APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATION
ze1v t Re-roofs
Sign ofApplmanucon — a�
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will to applicant w future building occupant atom or handle ha oat dose material
40 Ontd by the Cupertino Municipal Coda,Chapter 9.13,and the Hcalm and Safety
.Sailaa 25532()7All roofs shall be inspected prior to any roofing material being installed.
[3y 0441-
Will dee applicut or future building occupant us:equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hanrdnm air cnnummats as darned by the Bay Arca Air Quality Management all new materials for inspection.
District?
❑Yes Uflu
I haw mad the haaaNusmamriaisouporements under Cha sor6.95 ofthe Califor•
nim Health 8 SafctyCodc,Seco m 25505,25533and WX 1 annnrmam Matifdm building
don not currently haw:a len that It b my respamibiloy m oudfy dor..Pat of Ne
requirements which most be Ipriar m issence ofs cattleman Of ate Signature of Applicant Date
g b All roof coverings to be Class"B"or better
Owner uthorlad agent Dam