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04090116K p0 lei O i CITY OF CUPERTINO BUILDING DIVISION PEFMT &CONeTRACTOR INFbRMr��I©N - . e''*fw �. •:N# s. �-.NRv � iF?' s'4Aib3�"rtY?'S ' $Sr:,r^YS a BUILDING ADDRESS: PALISADE BUILDERS INC PERMITN004090116 OWNER'S NAME: PERMIT ISSUE DATE CUPERTINO HOUSING B; SANITARY NO. CONTROL NO. (650)470-4700 ARCHITECI7BNGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH [� 0 LICENSED CONTRACTOR'S DECLARATION Job Description I hereby affirm that 1 am liens ed under pmvislou Of Chapter 9 (commencing p with Section 7000) of Division 0 of the Business and ProfeWum Code, and my litmus is inicfcnlragane ertect Lmo g3Boy� NEW CONDO -1506 SQ. F.T. GaulConuxmr :SH1OG An;rM. ARCHITECTS DECLARATION I untlemtand my an hall o tau a public mcnNs pl , Licensed pme"'Onal W NER-BUILDER DECLARATION I hereby a10rm that 1 am exempt from the Conlranafa License law for the following mason. (Section 7(D 1.5, Business and Professions Cade: My city or county which requires a permit to construct, ager. W pmw, demolW. Or repair any auuclum pdor an its issuance. also requires the applicant forsuch permit m file a signed statement Sq. Ft. Floor Area Valuation that is licensed pursuant to the provisions of the Corrector's License Law (Chapter 9 (commencing with Section 7000) of Division 7 of the Business and ProfoimtsCode) or 17 4 3 3 4 that he is exempt therefrom and the basis for the alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of rest more than five hundred dollars ($500). ❑ 1, u owner of Die property, or my employees with wages u thebxle companudon, Re uired Inspections will Oct the work and the structure is nottrtteaded conflicted forest, (Sce. 7W. Business and Profe uum; Cade: The Command Lmeue law does not apply m an owner of q p property who builds or improves themoe,and whodoessuchwork himselfo Waugh his own employees, provided that such improvements are Out intended oscillated ferule. if. however, the building or Impmwmem is sold within ane year of oompletion, the owner. builder will haw the When of proving that M did not build or improve for purpose of talc.). ❑ 1. as owner of the property am exclusively contracting with licensed contractors to construct the project (Sec. 7044, Business and Profession Cade:) The Contsxxrk Li - come Law dIXJ not apply an an Owner or property who W(Ids or Improves dCRon. and, who contracts rex such projects with a eontrxmr(a) licensed pur ncet on de Cuntrxmr. License law. ❑ I am exempt under Sec . B k P C for this moon Owner Date WORKER'S COMPENSATION DECLARATION I hereby affirm under pemityof perjury one of the following declarations: 1 haw and will maintain. C.Nficamaf Cement to self -insure far WarkefaCempan- u0on, u pmvidcd for by Section 7700 of the labor Code. fm the performance of de work for which Wa permit is Vuned. ❑ I have and will maintain Wmker's Compensation Insurance, u required by Section 5700 of the Labor Cade, for the performance of the work for which this permit is intend. My Worker's Compensation Insurance center and Policy number art: Carrier. M040e67:! Z'AC Policy No.:4-7MM29d33 5 CERTIFICATE OF HEMP ION FROM WORKERS' ' COMPENSATION INSURANCE from seeder need not ne completed time permit is (moot hundreedelles ($100) or los) 1 certify that in the performance of the wock for which this permit Is treed. I shall nm employ any person in any manneran AS m become subject 10 the Workers Cnmpaodon Laws of California. Dam Applicant NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should become subject to the Worker's Compensation pmvutons of the labor Code. you most forthwith comply with such Provisions or this permit Mall ne doomed revoked. CONSTRUCTION LENDING AOENCY 1 hereby a1Tmn this then u a contraction lending agency for the performance of the work for which Nu permit is Wood (Sec. 5097, Civ. C.) Lender's Name L.mmes Aedmsa 1 certify that 1 haw read this application and main per the above information Is correct. I agree to comply with all city and county ordinumes and sum laws relating m building construction, and hereby authoiae mium utim ofthis city mentor upon the move -mentioned proparty for Inspection purposes. (We) agree in save, indemnify and keep harmless the City of Cupertino mgaimt liabilities. judgments, costs and espouser which may in any my accrue against said City In consequence of the Smoling of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT Issued by: Date SOURCE 5FOULATIONS. y�� Re -roofs Type of Roof �ti,/� / L� Slgnxurcor ApplmanU on ar Date HAZARDOUS MATERIALS DISCLOSURE Will Ilex applicant or fumes Wilding occupantmore or haulk haumdom maurial as deffned by the Cummins, Municipal Code. Chapter 9.13• and the Health and Safely Code• Sermon 25501(.)7 ❑ yes %I $' All roofs shall be inspected prior to any roofing material being installed. If a roof is installed without first obtaining an inspection, I agree to remove WIII the applicant or future building occupant use equipment or devices which II h.uOlmt air conteminanu as defined by the Bay Area Air Quality Management all new materials for inspection. Diruict7' J [3y.3rV}�_Nn I have mW W hasaNammmeria4 requirements underChaer 695 ofdc Califor. his Health& Safmy Cock, S cdo ;25505.25557 av1255N. lundcmand thmiftim Wilding does not currently hive a wnan4 the it u my mspemibinty to mdry the Occupant of the requirements which mum be mel met m issuance of a cerdficam of Occupancy. Signature Of Applicant Date All roof coverings to be Class rB" or better Owner or authorized age Date