05030312 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CON'TRAC'TOR=I N'EO2IATIO
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BUILDING ADDRESS: W E OINEIL CONSTRUCTION PERMIT NO.05030312
0500 TOWN CENTER LN 4 181
R'S NAME: PERMIT ISSUE DATE
SILVERSTONE DEVELOPMENT 5245 PACIFIC CMCQURSE DRIVE 08/29/200S
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0
�o0 LICENSED CONTRACIUR'S DECLARATION
i 8 1 punchy affirm IMI I am licensed under provisions of Chapter 9(mmmcncing Job Description
with Section 7010)ofDivuloo 3 of the Business card Professions Code.and my license is
+� .f 111 ceamdercm NEW CONDOMINIUM
'z Lkesecm Lk,w M 03/
ig' D.b Contractor r y_ 1124 SQ. FT. LIVING AREA
e3
ARCHITECT'S DECLARATION BMR UNIT/ NO CONSTRUCTION TAX
ndau
d I ucnJ my plans As shall bo used public records
G Licensed Professional
OWNER-BUILDER DECLARATION
1 I bomhy affirm onnl 11. exempt from the Canons Co License Law for the
fallowing mann.(cation 7 construct.alters end ere.demns Cole:Any city s county
which requires•permit re r ;meploy Improve,demolish,m e a sig ed awetam
—Zt pdorb,Ilmosnce,also require.thn,ishcamfor anchractm'to rile I.neJmbmem
< Nt(commencing
withSemmnttothcpfDiviansn ofINBtmctor'andPro Mw(Code)or Sq, F[. Floor Area Valuation
�$ (commcecixempt humfon7and of basis for
the Wcgcd essexe and Probations nCnde)of $130114
.. Nat M k exempt therefrom and ON bget,far Ne alleged exemption.My Woladan of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
nal more Nan five hundred dollar(SSW).
❑1,As owner of the property,m my employes with wages As their sok compensation.
will do the work.And the structure isno,intended moffered for Attic(Sm.70",Business Required cellons
and Profession,Code:The Conumimmm roan owner
tor's Lm Law does apply to of 9 P
property who Wildsarimprowa themon,andwho dessuch work himselfor through his
own seeployces,provided Wlsuch Improvemant,m not Intended oronered forgets.H.
however,the Wilding or Improvement is sold within one year of completion,the Owner.
Wilder will Mw the WNen of proving that he did nm build ger Improve fee prvpou of
sale.).
❑1,u Owner of the property Are exclusively contracting with licensed contractors;In
construct the penjmt(Sec.7044,Business and Prolusions Code:)The Contractors U.
mesa Law does not apply w an owner of prsparty who Wild(or improves thereon,and
who contract,for such projects with a contractor(s)licensed puwnl b the Contractors
License Law.
❑1 ons exempt under Sec. .B&P C fm NY won
—Dam-
MF
WORKER'S COMPBNSATION DECLARATION
I hereby salon under pointy of perjury ON of the following declarations:
1 have and will maintain a CeniBnm of Consent to self-Insum for Workers Compen.
sailed,o provided for by Section 37M of the labor Code,IN the performance of the
work for which this Permit Is Issued.
❑1 have and will maintain Worker's Compensation Insurance,u required by Section
3700 of the Labor CAN.for the performance of the work for which this Permit is Issued.
My Workers Compensation Insurance tamer m,#Policy number am:
C.nmr..�-V /C# jn0 ,(ti oney No.:LG?S3202
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section rued notbecompkud if tbe permit is fm NA hundred doom($I00)
or leu)
I unify,that in the performance of the work for which this permit is issued,l Nall not
employ any Foment in any manner an As to become subject to the Worker'Compensation
Laws of California.Dau
Applicant
NOTICE TO APPLICANT.If,after making this Cer irate of Exmnplion,you should
become subject to the Workers Compensation provisions of the labor Cade,you most
.J O foMwith comply with such provisions or this Permit W deemed rtwked.
.Zi tiCONSTRUCTION LENDING AGENCY
t" Ihumby Lfn m that them is a construction lending agency for the performamx of
�i > the work for which this permit is stood(Sm.3097,Civ.C.)
I[)Q Lenders Name
2 Lenders Add.
V Q 1 comfy that 1 haw read this apPllcation and sum that the above immma0on is
.LL. coomm 1 agree to comply with all city and county ordinances and stab laws mlating m
O building construction,and hereby aubodm representatives of this city b enter upon AN
LS7 above-mentioned property for Inspection purposes.
(We)agree to gave,indemnify and keep harmless the City of Cupertino against
r.t ran liabilities,judgments,cam and expenses which may In any way acerae against said City
(„)2 In consequence of the sy mbg of this Permit.
F7 APPLICANT UNDERSTANDS ANDWILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
8/zqZ@ f- Re-roofs
Signal, App casX.mmatimT Date Type of Roof
HAZARDOUS h ERIALS DISCLOSURE
Will the applicant Or future Wilding occupant swam arbandlc haardous material
tined by the Cupertino Municipal Code.Chapter 9.13,and the Heald and Safety
Section ya25372(a)7
❑ t�� 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 to remove
emit haxardnus air contaminants as defined by the Bay Area Air Qumly Management all new materials for inspection,
District? /
❑Yes t4w
I have real the ham rdousmncehls mquimmow under CMpan6.95 ofbe Califer-
nt,Health&SsfctyCed SoW=25505,25533and25534.lunderundthtifdc Wilding
does MI CuMaMlY Mw a,neck IMt kol mumenslbllily,to Acuity IW mtlpNl of thC
requimmAnts which most N melp'r nW.of a Centric Of Occu Signature of Applicant Date
owner ulhar<a agent 9�zT Dam All roof coverings to be Class"B"or better