05030304 CITY OF COPERTINO ragm�Ts x" �e n
BUILDING DIVISION PERMIT hCONTRACTQR INF0RMA' TT0N:,°
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION Pr'IMITNO'05030304
.R'S NAME: PERMIT I55UEDATE
SILVERSTONE DEVELOPMENT 5245 PACIFIC MNIZOURSE DRjVE QR/29/2005
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCH11MMWGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 I�
Sop LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby affirm that 1 em licensed under provisions of Cheplcr 9(commencing
with Settle.TOM)of DIA.W.3 of the Business and Profession,Code,and my lice..is
into Formandarcem. NEW CONDOMINIUM
;E3 Lkwmcl u.. 449446'3
Dem cnmhacmr yr e.r 1230 SQ. FT. LIVING SPACE
0 ARCHITECTS DECLARATION
1 understand my plana shall he used u public records
y C Licensed Pmfcssimul
OetNEm"wompUILDERfrom
DECLARATION
0 I thereby.(fuse Net I em exempt from the Contractors Ueanu Lew for the
D o whip regmoon.permit
t 70013, t,aims and Prow,de o demolish.
Coda:Any oily er counre
5$Tri which myuisn a permit m construct,elms Impmw,demelinh..r repair any aWaum
print in its iuuance,also mqume,the applicant for such Pamir to rile a signed ammmmt
£-£z rho he u licensed pmmant m the provisions of me contncmr's Ucmnse Law(chapter 9 Sq. Ft. Floor Area Va1�aTiA18384
Y�m (commencing with Section 7000)of Division 3 of the Business and PmeMons Cook)OF
$ Net he Is eumpt themfmm and the basis for the Oleged sorption.Any violation or
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
oat mom than fiw hundred dollen(g50y. 36940002 . 00
❑1,ummar of die Property.m my employees with wagesu their mlecompensuton,
willdo the work and me a=..ismointandW oroaerW forage(Sm.7044,Business Required Inspections
and Professions Code:The Comeacmfn s Licems,law donot apply m e an owner of q P
property who bui Ida or improsea Nemon,and who does such work himself or through his
own employees,provided that mch Impmwments ase not Inended oroRered for We.If,
hnwewr,me building or improvement is mid within one yew of completion,the owner-
boister ,will as.the buNan of proving that he did not build or impmw for P.F.of
um.).
❑1.u owner of the property am exclusively contracting with licensed contractors to
consumct the pmjm(See.7044.Business and Pmfnsians Code:)The Contractor's Li.
Cents,law don not apply a an owner of property wholMids or improvss Berton,and,
who contracts for such pmjcm with a contracmNs)licensed pwsusnt.the Communes
License law.
I am exempt under Sea. ,B a P C for this reason
Dam
WORKERS COMPENSATION DECLARATION
I hereby afarm under penslty of perjury one of the following decimations:
rI 1 haw and will maintain a Cereftem of Consem to self-Insum forWormesCompen.
cation,u provided for by Section 3700 of the labor Code,for the performance of the
work for which this Permit is Issued.
❑1 haw and will maintain Workeez Compensation Insurmm,u required by Section
3700 of de Labor Code,for the performance of the work for which Nis permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
C"er.2 u/te!/-fl�Q//�1✓ Policy No.:y/G Yr,?3 Ja 3-a
CERTIFICATE OF EKEM MON FROM WORKERS'
COMPENSATION INSURANCE
Ohisuctlnn need rent becompleted If the Permit Isforanehhndmd dollen($10)
or lees.)
1 cenifv that in the performmce of the work for which this permit O issued.I shall not
employ any person in my moneran u m become mbjecl m the Woraus'Coreperaation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:If,after making this Camincate of Exemption.you should
become subject to the Wohefs Compensation provisions of me Labra Code,you must
.J 0 forthwith comply with such pmvidons or this permit shall be deemed metd.
e
tiCONSTRUCTION LENDING AGENCY
E~ I hereby from that them its conmuction lending gency for the performance of
�i 7 the work for which this permit 4 issued(Sec.3097.Ch,C.)
W 0 Le ohm's Nurse
7 z Lcomes Address
U Q I cenify that 1 Mw mad this application and sum that the straw inform Wm is
Dr ;'! towel.I agree in comply with all city and county a it ances and tmm laws totaling to
O VC building cmuwetion,and hereby mthodm reprnenadws of this city OF enter upon the
W show-mentioned property for inspection purposes
(We)agree an sew,indemnify and keep humleu the City or Cupertino agaivt
N Iiabllitim,judgments,core and expense which may In my way accrue against said City
U 7 in consequence of the gaming of mis perm ll.
F7 APPLICANT UNDERSTANDS ID WILL COMPLY WITH ALL NON-POINr Issued by: Date
SOURCE REGULATIONS.
B171'14 Re-roofs
Signuu fApp ienVContractor Dau •�� a of Roof
HAZARDOUS I r TERIALS DISCLOSURE TJ p
Will the applicant or future building Occupant store or handle Inuum ous material
Mcd by the Cupenin t Municipal Code,Chapter 9.13,and de Health and Safety
Section 25532(a)7 All roofs shall be inspected prior to any roofing material being installed.
Yu
Will the applicant of future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
cmll haardnus air contaminants u donned by the Bay Area Air Gustily Manegemem all new materials for inspection.
District?
❑Yea (7JJ1b
I haw mad the hwndousmucrhh mquiremenu under Chapter 6.95 ofdhe pular.
nia Hut"SarciyCede.Section 25505.25533 ux125534.1 understand thatifthe building
dors not currently haw a.nem,mn I it y map modbilby to nNry the occupant lir the
reyulrtnenu whkhm uEc sect pee aancenaeeniream tar Oc span Signature of Applicant Date
�� All roof coverings to be Class"B"or better
Owner oti6thorind agent e5l Dam
C