05030257 CITY OF CUPERTINO 7.° 7777 T
BUILDING DIVISION PERMITC�NTI�A.CTO�.t INI±'U. VIA' IO1V .
BUILDING ADDRESS: W E O'NEIL CONSTRUCTION PERMIT NO.05030257
R'S NAME: PERMIT ISSUE DATE
SIVLERSTONE DEVELOPMENT 5245 PACIFIC 08/29/2005
PHONE: SANITARY NO. CONTROL NO.
(510) 385-0121
ARCHITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
'.op LICENSED CONTRACTOR'S DECLARATION
rd I Wouby Affirm that I Am Hennaed under provisions of Chapter 9(ro anomeins Job Description
with Section 70(10)of Division Sof flan BushmeaaW ProfeasiaN CNW.and mylicemse la
in wimccancleffen. NEW CONDOMINIUM
Data col `arm 743 SQ. FT. LIVING SPACE
Data Cm DELL �_
ARCHITECTS sed DECLARATION
1 undersand my Ptsns sIW l he used As public ieeards
5 UUl-
G03
Licensed PN(e1NOMI
.] OWNER-BUILDER DECLARATION
he
I reffirm by athe 1 exempt
CsOO
cmpt from Urs I LicenseLicenseLaw for the
p o following mama.(Semon 7(D 1.L5,Business and Professions Code:My city m county
5$ which rtquires•porno to construct,slur,improve,demolish,or e a Aimed
im d ttrnm Ant
-i y timor hat he its issuanee,atmnt 10 resft lhovisiApplicant ofor such comanc n's ucco sipw(chapter
statement
(commencing
pursuant 7000)of
Division
of use mrmlursUcensc UwfChanlm9 Sq.Ft.Floor Area Valu X6009
go (commencing with Session 70D0)of Division)of the Business and Profeuloas CaOe)ur
f 5 F That he is exempt therefrom and she basis for the alleged co empsian.My violation of
Session 7031.5 by airy applicant fee a permit subjects W applicant to a civil penalty of APN Number Occupancy Type
not mom dun five hundred dollars(M). 36940002 . 00 -
❑1,As owner of the property.oe my employees wlib vmges As their sole sampeaudon,
will do the wart,and the swmure N not Intended or a@red for state(Sec.7044,Busitmss Required Inspections
and Professions Code:The Cnmsscmrs License Law Ones Out apply one an owner of q P
pmpmy who but Ida m Improves thereon,end who does such work himael f Or through his
own employs,provided that such improvements ase not intended reoffered for sale.IL
however.the building or improvement Is mid within one year of corepleuea,the owner.
Wilder will have the burden of proving that he did not build or Improve for purpose of
esu.).
0 I.as owner of the ptapeny,am exclusively contracting with licensed mn=AOA to
construct the proky,s(Sec.7016,Business and Profusions Cade:)The Contrmtm's U-
cense law ds not apply an an owner of property who builds or Improves themen,and,
who mmmcu for such projects with a conuacter(s)licensed pursuant m the Contractor's
License Law.
❑1 am exempt under Sec. .B&P C for this reason
Dam
WORKER'S COMPENSATION DECLARATION
I hereby affiml under penalty of perjury one of the following dealamdons:
❑[ham and will maintain aCertlficumof Consent to mlfdnsure for WorkcesCompen-
suion,As provided for by Section 37DO of the labor Code,for the performance of floe
work,for which this permit Is wood.
❑1 have end will maintain Worker's Compensation Insurance,As requited by Section
37W of the Labor Code.for the performance of the work fu which this permit is iuued.
My Workers Compensation Insumme camas and Policy number ase:
Cader:QU PC&-+V t4I /h✓Policy No.:_,e 3S?3/03'O
CERTIFICATE OF EXEMP130N FROM WORKERS'
COMPENSATION INSURANCE
Cnnuuctian need notMcmnpleted If the permit is for one hundred dollars(11 W)
or less)
I certify;that in the performance of the work for which this Pamir is ismed,I shall am
employ anypeimn in any mannerm As m become subject to the Worked Cempensadon
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption.you should
hecome subject no the Workers Compensation provisions of the Uttar Codc,you mus
O forthwith comply with such Provisions or this permit Mall be domed mated.
Z r~�.. CONSTRUCTION LENDING AGENCY
[.r I hereby affirm that Nero Is amnewcflm lending agency far the Performance of
�i dm work for which this permit is issued(Sec.3097.Civ.C.)
dQ Lenders Name
.7 z Lenders Address
U O 1 certify that 1 have mud Woe application And sem that the above informulun is
ly F
cam"I agree As comply with all city and county ordinances and tum laws relating te
OU building consmmtion,and hereby millodm mprommtives of this city m enter uPnn use
GLI above-mension cal property for Inspection purpoats.
fY (We)agree to save,indemnify and keep learmless the City of Cupertino against
vy rA liabilities,judgments.cues m
and expenses which may In my way acce agalm said City
U in APPLLIeof the RNof rses
ICCANTUNDESTADS AILL COMPLY WITH ALL NON-POINT Issued by: Date
SOU EREGULA NS.
8 S Re-roofs
Signa ppincuVConummr Disc
HAZARDOUS ATERIAIS DISCLOSURE Type of Roof
Will use applicant or future building occupant am orhandle hamel material
fined by the Cupertino Municipal Code.Chapter 9.13,and the Health and Safety
Sectio 35532(a)7All roofs shall be inspected prior to any roofing material being installed.
Yes
Will she Applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emll hazardous air conmminanu As dermad by the Bay AMA Air Quality Management all new materials for inspection.
Gimlet? hie�/
Oyu hive
1 have mad the hazardous materialsrequimmenu under Chapter6.95 of the Celifos
nia Health@Safety Code,Section 254415.35533 she 35536.1 understand NS lfthe building
dace not cunenlly hew a unant,that Itmy resports ly m notify rhe occupant of the
requirements which must be mel p II U.C.of A Ccmficam of Oc upancy. Signature of Applicant Date
�
8 r All roof coverings to be Class"B"or better
own aulhodvedagent am
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