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04090215CITY OF CUPERTINO 0 U W GY y gds a.,. ©1Vy�'R 'URA^` o BUILDING DIVISION PERMIT BUILDING ADDRESS: PALISADE BUILDERS INC PERMIT NO. 04090215 OWNER'S NAME: PERMIT ISSUE DATE SANITARY N L NO. ARCHITECT/ENGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH l� l� LICENSED CONTRACTOR'S DECLARATION Job Description I hemby of rm that I am licensed unicr provisions of Chapter 9 (commencing ]Ol of Divitlon 3 ofthe Bunnus end Profeulnnn Cnde, end my license h withll fn. Affect. ,leen(ane arta cnen. License Glu Llc.p NEW CONDO - 1530 SQ'. FT. Dem D Conlrscror h Cg9/f L ARCHITECTS DECLARATION _ I understand my plans shell be tad as Puhlfr wtttll�— IZ Licensed Professional OWNER -B ER DECLARATION I hereby affirm that I am exempt from the Contractor', License Lew for the fallowing reason. section 7031.5, Business and Profesrians Code: Any city at county which requires a permit to convect, elmr, Improve, demolish, or mpeir any structure prior m its issuance, also requires the applicant for such permit ro file a signed statement Sq. Ft. Floor Area Valuation that he Is licensed pursuant to the provisions of the Contractor', LlWnm Law (Chapter 9 (commencing with Section 7") of Division 3 of the Bostneea and Profession, Code) or Net be is exempt therefrom and the Asian for W alleged eumplion. Any violation of APN Number Occupancy Type Section 703 L5 by any applicant for a permiuubjects the applicant to a civil penalty of not Rome man five hundred dollars ($51001. ❑ 1, u owner of the pmpmy, or my employees with wages u their Role compensation, 31620084.00 Required Inspections will do me work, and lhemuchea team Intended Muttered fonelc(Sm. 7014, Business Rod Profusions Code: The Contrscme, License Law does not apply m an owner of 9 P property who builds m improves thereon, and who deeuuch work hi msel f or through his own employers, provided that such tmprmsmuD eA not Intended Mattered ferule. If, however, the building or Improvement Is sold within one year of completion, be owner. builder will have the burden of proving that he did not build or improve for purpose of seta.). ❑ i, a owner of the property, am exclusively contracting with licensed conbmtnn to construct the project (Sec, 704t, Business and Professions Coda:) The Conhutor's Li. cense Law does not apply ro in owner of properly who builds or improve thereon, and, who contracts for such projects with a conlrectoKU licensed pursuant to tins Codirector, License Law. ' ❑ 1 am exempt under Su. . B k P C far this rcuan Owner Dam WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: ave and will maintain • Certificate of Consent to self -Inure for WorkersCompen- eation, u provided per by Section 37M of the ober Code. for me performance of the work for which this permit is issued. ❑ 1 have and will maintain Worker's Compensation Insurance, A required by Section 37M of the Letter Code, for the performance of me work for which this Permit 11 Issued, My Workers Compensation Insurance carrier and Policy number am: Center: As 4,T, 57-'C ,Tg✓G'Poliry No.: C10npm 4xs3�C� ' CERTIFICATE OF EXEMPTION FROM WORKERS' COMPENSATION INSURANCE (Thi, mcdou rood not becomplcmd If the Permit Isfbrone hundred dollen ($IN) m less.) I edify that in the performance of the work for which this Permit is Issued, I shell not employ any Person in any manor an as m become object to the Workers' Comprnsslton Laws of California. Dam Applicant NOTICE TO APPLICANT: If, efer making this Certificate of Exemption, you should become subject m the Worker's Compensation provisions of me labor Code, you must forthwith comply with such provisions or this permit shell be deemed rooked. CONSTRUCTION LENDING AGENCY I hereby affirm met mea i, a consuuctinn lending agency I'nr the performance of the work for which this permit is issued (Sec. 3119'1, Civ. C.) Lenders Name Lcnder'n Mikes, I certify met I have read this application and sum that the show information is correct. 1 agree ro comply with all city and county ordinances and some laws relating to building construction, and hereby authorize reposenmives of this city to cnu:r upon the Move-meniumed properly for inspection POMOMS. (We) agree I. save, indemnify Rod kap harmless the City of Cupertino against liabilities, judgments costs and expenses which may in any my =me against Aid City In consequence of me gaming of this Fermi, APPLICANT UNDERSTANDS AND WILL COMPLY WI LL NON -POINT Issued by: Date SOURCE REGULATIONS. Re -roofs Typo of Roof 2h Signature of AppllcanVConlrAtm Do, HAZARDOU ERIALS DISCLOSURE Will me applicant or ful uildingmeupant Bore or handle ImMrdous material I defmcd by the Cupmino Municipal Code, Chapter 9.12. and the Halm And Safely Cade. Section 25532(a)7 I All roofs shall be inspected prior to any roofing material being installed. ❑ Yrs If a roof is installed without first obtaining an inspection, I agree to remove Will the applicant or future building occupant use equipment or devices which t hazardous air contaminants u dented by the Bay Arca Air Quality Management all new materials for inspection. tufa? ❑Yes I he. read the harardaus materials requirements under Chapter 6.95 of the Cali for- nia Health k Safety Cade, Sectioas 25505,25533 and 23534.1 understand that ifine Wilding does not currently hove a team, that it is my responsibility to notify the Occupant of the mquiremcnts which must he mel oruiuumaofa CemOcmmor Occupacy, Signature of Applicant Date All roof coverings to be Class "Bt' or better Owner tar authorized agent oat/