05030281 (2) CITY OF CUPERTINO
BUILDING DIVISION PERMIT C,ON Jue'TOR TNVU iMA' 1UN .
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO.05030281
OWNER'S NAME; PERMIT ISSUE DATE
SILVERSTONE DEVELOPMENT --.5.24c; PACIFIC C()N(--()URc;E ng vE 5
E; SANITARY NO. CONTROL NO.
510 385-0121
ARCHTIECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
+�+op LICENSED CONTRACTOR'S DECLARATION Job Description
V 1 hereby affirm Thal 1 em licensed under provisions of Chapter 9(commencing
with Section 7001H of Division Sof the Business and ProremlUN Code.and my license is
in full fan"and
EEz LiaesaCl Lie.I N9N 63 / NEW CONDOMINIUM
Daw contrava, I✓ fl ARCHITECTS DECLARATION 1116 SQ. FT. LIVING AREA
1 understand my Pisos shell he used u public records
4O Licensed Pmfesvonal
OWNER-BUILDER DECLARATION
<I I hereby affirm
that I am exempt from tie Contractors Ltcenm law for the
1:40 following won.(Section 7031.5,Businus and Profession Cade:My city or county
$ which mqutros a permit to canmac4 cm improve,dcmoi W,m repair any structure
fZi prior to its issuance.also require,de applicant for such Permit w file a signed summent .
E G dal heis licensed pursuant toNcprovisions ofthe CommemrsLiam Law(chapter 9 Sq.Ft.Floor Area Val*1"188
m�$ (commencing with Section 7000)of Division 3 of the Bustrucal Professions Code)or
.. tbat he is exempt therefrom and the basis for the alleged exemption.My violation of
Seedon 7031.5 by any applicant for a permit subjects the applicant w a civil penally of APN Number Occupancy Type
not mart than five hundred dollars($500k 36940002 . 00
0 I,m awes,of the property,m my wploy=wed wgos u their mk compewdon,
will do de work.and tesw"Ime is not hooded of offered for We(Sao.70th.Business Required Inspections
aod professions Cade:The Contractors Lieme n e Law dorot apply to an owner of q P
property w ho MI IM or Improves thereon,and who don such wok himself or through his
.employ=.provided that inch Improvements use notinended"offered for We.IL
however,the building or Improvement is sold wiwn ora year of completion,the owner.
builder will have the burden of proving that he did not build or Improve fm purpose of
soln.).
0 1,as..,of the property,em exclusively contracting with licensed conuscton to
concoct the project(Sec.7W,Business aid Profession Code:)The Contractors LI-
cenee law don not apply to an owner of property,who builds or Improv¢thereon,and,
who contracts fm such projects with a eonuactor(a)Ilcenred pursuant to the Convenors
License Law.
❑I an exempt under See _ .B k P C for this masers
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby arnow under pointy of perjury one of the following declwlon:
737.00,'or
hive and will maintain a Certificate ofComenno self-insum fm Workers Compen-
.u provided for by Sinton 3700 of the Labor Code,for silo performance of the
for which this permit is imued.
have and will maintain Workers Compensation Insurl u required by Section
the Labor Code,for the pedarm race of the work far which this permit is Issued.
orker's Compensation Insurance carrier and Polity number me:
ler>.(/RyL{f-Irt✓I eA1 CA--Polley Na.:j._t)f?31Q
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thu section need not M completed If the permit is for one hundred dollars($1000
or loss.)
1 certify Not in the performance of the work for which this Permit ls bound,l shall not
employ any person In any meaner In as to become subject to t aworben'Compensation
Laws of California.Date
Applicant
NOTICE TO APPLICANT:If.after making this certificate of Exemption,you should -
memne,subject to the Workers Compensation provisions of the Labor Code,you most
.�z forthwith comply with such provisions or Nis permit shall W claimed revoked.
zCONSTRUCTION LENDING AGENCY
[-n rte., Ihereby&Mm that were is a construction lending All for the Purfurmmce of
CL the work for which this permit is issmd(Sec.3097,Civ.C.)
Q Lenders Name
av
a z Lenders Addw
U0 I seemly,that I hers read this application end slow that the whom Information is
IL F correct.I agree to comply with all city Ind county eminences and sow lave misting w
O V building concoction,and hereby authodre aprommanives of this city to cnwr upon the
[27 above-mentioned Property for inpcnion purposes(We)
se
(We)agree to an,indemnify and kap hamless geW
the City of Cupertino st
o-„rrAA liabilities,judgnumm,cow and expenses which may in anycoy acrnse against mid City
U z in consequence of the l; ling of this permit.
�+ APPLICANT UNDERSTANDS AyD WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCEREGUI.A'I�ONS. _'!!/
Gy �/L/L+�✓ 8j4y1,60 Re-roofs
SignatureTApplicamoCombector ell DAM Type•'
MATERIALS DISCLOSURE pe Of Roof
Will the applicant or fuwm Wilding oceupmt some or handle hma dom mawrial
as defined by the Cupertino Municipal Code.Chapter 9,12,and tie Health and Safety
Coda.Section 25532(x)? di,, All roofs shall be inspected prior to any roofing material being installed.
1oYea
Will the applicant or future building occupant use equipment m devices which If a roof is installed without first obtaining an inspection,I agree to remove
mil lus air emmeminsn m dcri d by use Bay.Ama Alr Quality Menagemcnr all new materials for inspection.
District?
0 Yes u
I ham mad the haardous materials mcluimmenuunderChapur 6.95oftM Califor.
me Health B Safety Cade,Sections 25505.25533 and 25534.1 understood dud lftie building
does not currently hero•tenm4 the it is my MAnsibilby to notify de occup e,of do
requirements which most the met prior w' cc ofa CenllicawolOccu Signature of Applicant Date
X1 All roof coverings to be Class"B"or better
Owner or offitraircd agent Ds