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04090168�86 n BO3�f�22f�� J �FFbF< 4 a UV i CITY OF CUPERTINO t BUILDING DIVISION PERMIT 1 1I� , M dm YiW4, . . BUILDING ADDRESS: PALISADE BUILDERS INC PERMIT N0. 04090168 OWNER'SN ME:TEVBDi8 eRK # 3B8 PERMIT ISSUE DATE SANITARY N OL NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG EO PLUMB MEOCH LICENSED CONTRACTOR'S DECLARATION lob Description P I hereby affirm that l am licensed under provisions of Chapter 9 (commencing with Section MIKE of Division 3 of No Businuaand Professiiotns Code.und my license is in full force andeffec �jsp©-{/ Licence CIO Lm.g V f0 NEW CONDO -1478 SQ. FT. _ Dole CnmfaCWr f-S�1aiG ALK �Ot'�_ ARCHITECT -S DECLARATION I understand my Id.... ed u Pohlic recur , Licensed Professional OWNER -BUILDER DECLARATION 1 hereby smrm that I am exempt from the Contractor's License Law for Ibe following msson. (Section 7031.5, Business and Professions Code: Any city or county . which requires a, permit to construct. altar, improve, demolish, or repair any stmnum prior In its issuance. also requiresthe applicant for such permit ro file a signed statement that he is licensed mounted in the provisions of the ConmclorY License Law (Chapter 9 Sq. Ft. Floor Area Valuation (commencing with Section 7") of Division 3 of the Business and Professional Code) in that he is exempt therefrom and me basis for me alleged exemption. Any violation of APN Number Occupancy Type Section 7031.5 by any appllcmt for a permit subjects the appiiCML 10 a civil penalty of not mom than love hundred della. ($500). ❑ 1, as owner, of the property, on my employees with wages u their sole compensation, 31620084.00 Required Inspections will do me work,and me structure n ml intended or offered forulc(Sec. 70U. Resume and Professions Code: The Contractors License Law rima not apply m an owner of q P property who bud Ids er improves mercer, and who doea such work h Imself or through her own employees, provided that such Improvements see not Informed uroRered for sale, IL however, the building or improvement is sold within one year of completion, the owner. builder will have the burden of proving that he did not Wild or Improve for purpose of sal. I. ❑ L as owner of the pmpeny, am exclusively contracting with licensed coot.no. It construct the project (Sm. Irises, Business and Professions Code:) The Conusemr's Li. cense Law dons not apply he an owner of property who Wilda or improves themon, and, who coniine, for such pmjec%with a ennuaclor(a) licensed pursuant in me Comraerors License Law. ❑ I am exempt under Sec. . B & P C for this moon Owner Dem WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury ore of tbe following declarations: aw end will maintain a CoNftcam of Coment to self -douse for WoduesCompen- andan, u provided fm by Section 37011 of the labor Code. for me performmce of the work for which this permit is issued. ❑ 1 have and will maintain Workers Compensation Insurance, u required by Section 7700 of me Leber Coda for me performance of the woh for which this permit is Issued. My Warkeeg Compensation Insurance artier and Policy number am: Carne, TwG Policy No.:G20L'M7�Y5 CERTIFICATE OF EXEMPTION FROM WORKERS' ' COMPENSATION INSURANCE (phis section recd not becomplemd little permil Is finem hundred dollars (SIM) ICat) 1 ceAfy that In the performam, of the work for which mit permit is leaned, I shall not employ any person in any manner so in to become subject to Me Worker' Compensation Laws of California. Dam Applicant NOTICE TO APPLICANT: If, after making this Cenificale of Exemption, you should become subject to the Worker's Compensation provisions of the Labor Cede, you fowl forthwith comply with such previsions or thin permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY 1 hemby affirm than there is a construction lending agency for the performance of the work for which this permit Is Issued (Sec. 3097. Civ. C.) Tendo'. Name Lender's Addreag I certify that i have mad this application and sum that the shove Information is comet. I agree to comply with all city and county onfinances and sum lasso rotating m building construction, and hemby amhorlaL mpresenuldves of this city to enter upon the ahnve-mentioned property for iMPemien purposes (We) agree to save, indemnify and keep harmless the City of Cupertino against liabilities,judgments, and expenses which may In any way Be..c .gains, nim City areas 1. consequence of me APPLICANT UNDERSTANDSof IANhinD WILL COMPLY WITH ALL NON -POINT Issued by; Date SOURCE REGULATIONS. Re -roofs Type of Roof /%��------- 4f-2 h05 Stgmmum ofAitilicannicassifilmi Dam HAZARDOUS MATERIALS DISCLOSURE Will me applicant or future building mcuPam more or handle ha.rdous material an defined by the Cupertino Municipal Cede, Chapter 9.12. and the Health and Safety Code, Section 25532(a)7 v' All roofs shall be inspected prior to any roofing material being installed. ❑ Yeses If a roof IS installed without first obtaining an inspection, I agree to remove Will the applicant or future Wilding Occupant use equipment or devices which hasardous air corimminaouq u &fmcd by the Bay Area Air Quality Management all new materials for inspection. nutlet?V ❑Yes I haw mW the hmaMnusmaurials mquiremerm underChapfor6.95 ofine Califor. nia Halm& Safety Code, Smdons25505,25533 and 25531.1 understand mu ifthe building rima not curenlly haw a amanl, met It is my responsibility m nedly the occupant of me requimmenot which must be met poor to issuance of a certificate of occupancy. Signature Of Applicant Date -2/ -4> All roof coverings to be Class "Bt' or better Ownerseramhoriacdagent D lc