06010054BUILDING DIVISION PERMIT
1 Mmby affirm that I am licensed under provisirns of Clupicr 9 (commencing
with Section 7") of Division 3 of the Business orb Professions Code, and my license is
I. full tome and effect. !�
License Class R Lie. N V
Dam 1-1hn4, Contractor.
ARCHITECTS DECLA9ATT0N
z U I undersand my plans shall le used as public records
0
O Licensed Pmressiunal
3 OWNER -BUILDER DECLARATION
<21 hereby affirm that 1 am exempt from the ConlmetoYs License Law for the
M o following maven. (Swoon 7031.5, Business and Professions Cods: Any city or county
K m which requires a Permit to consumer, alcor, improve, demolkvh, or repair any suuctum
°Zy poor In its issuance, also requires the applicant for such permit to file a signed statement
W< that he is limned pursuant to the provisions of the Contractor's License taw (Chapter 9
(commencing wish Section 7000) of Division 3 or NC Business and Professions Code) or
e R — that he is exempt themfmm and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred dollars (M),
and Professions Code: The Contractor's License Law docs not apply As an owner of
property who builds cr improves themon, end who does such wart himself or through his
own employees, provided that such improvements Are not intended moneyed forsale If,
however, the building or improvement is sold within one year of completion, the owner-
Wildnr will have the burden of proving that he did not Wild or improve for purpose of
sale.).
❑ 1. as owner of the property, am exclusively contracting with licensed contractors to
constmct the project (Sec. 7044, Boathouses and Professions Code:) The Conuacbh U.
cense law docs not apply to an owner of propeny.who Wilds or improv thereon, and
who contracts for such projects with a contractor(s) lieerded pursuant to the Conuaemri
License taw.
❑ 1 am exempt under Sw. , B Jr P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
I hereby aRrm under penalty of perjury oro of the following declarations:
FI ha1 ham and will maintain acc,urmem or consent an self-insum for Worker's Cori
nation, as provided for by Section 3700 of the IaWr Cade. for the performan¢ of the
work for which this permit is issued.
❑ 1 have and will maintain Workcfs Compensation Insurance, As required by Section
3700 of the labor Code, for the performance of Ne work for which this permit is issued.
My Worker's Compsnsadan Insurance carrier and Policy number am:
smite wood not Its, completed ifthe Permit u for one hund it dollars(SIM)
1 certify Nat in she performance of the woh for which this permit 4 word. I shall not
employ any person in any manner sn As to become subject o the Woftos' Campensadon
Laws of Califomia. Dam
Applicant
NOTICE TO APPLICANT: If, aper making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you most
.Jz foMwuh comply with such provisions or shis Permit shall W deemed revoked.
z O CONSTRUCTION LENDING AGENCY
(•+ l hereby strum that them is a construction lending agency [or the performatme of
tYi the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
.D. z lender: Address
U Q 1 certify that I have read this application and sum that Ne shove information is
w f cmmecL I agree 10 comply with all city and county ordinances and tam laws misting to
0Ubuilding concoction. and hereby authodm mmrsemativ of this city to enter upon she
i" G show-memioncel properly for impecoon purposes
(We) agree to save, indemnify and kwp harmless time City of Cupertino against
H h liabilities. judgments, costs and expenses which may in any way&come against mid City
U z in consequence or the granting of this le.iL
^ APPLICANT UNDERSTAyDS AND WILL COMPLY WITH ALL NON -POINT
SOUBCEsREGULAT10N5/ P
/- /-o I,
Wtll use appucam or boom Wilding occupant atom or Wndic hmallous material
lined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Section 25532(.)?
0Yes l6No
Will tho applicant or future building =upon[ use equipmem or devices which
havard ow air cunaminsnts u dcOned by the Bay Am. Air Quality Management
Ycs ANO
6.95mfthc Califor.
d lhatifthe Wilding
the occupant of she
PALISADE BUILDERS INC
0)470-
Ytlnrott ""06010054
PERMIT ISSUE DATE
01/11/2006
SANITARY NO. CONTROL
BUILDING PERMIT INFO
Job Description
REVISION-STRUCTURAL.CALCS FOR
LIGHT POLE
31620084.00
Required Inspections
Issued by: (jW1lJV Date / 1/_a r -
Re -roofs v
Type of Roof
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
all new materials for inspection.
Signature of Applicant Date
All roof coverings to be Class "B" or better