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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
-7CUNTRACTORNFORMATION
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NN090111
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING
E:
SANITARY NE CONTROL NO.
(650)47D-4700
ARCHITECTIENGINEER:
-
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
P
1 hereby affirm that 1 am licensed under previsions of Chapter 9 (commencing
with Section 7M) of Division Sof the Business and Prolcmimu Code, and my license is
,
In full force and effect.
Si38 o46
NEW CONDO -1130 SQ. FT.
License Cl tical
A CHITECTS DECLARATION
1 % �d my plans
� he used a P Wic IecnNs
Licensed Professional a
OWNER -BUILDER DECLARATION
I hnmby afrinn that I am exempt from the Contnctoes License IoW for the
following reason. (Section 7031.5, Business and Pmfessloa Cade: My city or county
which mquims • permit to construct, alter. imprew, d OIL%h. m repair any n LAIMC
prior in its issuance. also requires the applicant forsuch permit to file a signed statement
that he is licensed pursuant o INC provisions of the Comracwr's License law(Chapmr 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Cele) or
13 (] 8 (] 8
than he u exempt themfmm and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Season 7031.5 by any applicant for a peril objects the applicant to A civil penalty of
nut more dun R. hundred dollars (2300).
❑ 1, as owner of the property, ser my cnployces with wages As their sake compcnation.
aired Inspections
Will do the wad[, and the structure W not intmdedar Offered far see(sm. 70th, am'Re
end Professions Cade: The Commewes Lianas LAW does not apply to an owner of
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property who build, Or impmws thereon, and who does uch work himselfor through his
Avon employees, provided that such Improvements an not mumaled or offered foram. if.
however, the building or improvement is sold within one year of completion, the Owner.
WilderWill law the burden of proving that he did nm Wild of Improve for purpose of
oke.).
I] 1. As Owner of the properly am exclusively contracting with licensed conuacwn to
construct the project (Sec. 7014, Business and Profession, Code:) The Conmcmb U.
come Law does not apply to an owner of property who bullds or improves thereon, and,
who contracts for such projects with a conmsemr(0 licensed pursuant to the Contractor's
Lorena law.
Lamesemptunder See .BhPCforlhisnaoo
Data
WORKER'S COMPENSATION DECLARATION
iwner
I hereby alarm under penally of perjury one of the following declan tans:
1 haw and will maintain a Cerdftesu of CmAse nt w sel6laure for Waftes COmpem
i^, a provided for by Sagan 7700 Of the Labor Cade, for the performance: Of the
Work for which this permit u bound.
❑ 1 haw and will maintain WoAces Compensation Instoomm, a required by section
3700 of Ne labor Code, for the performance of die work for which this peri, is Issued.
My Workees Compensation Insurance carrier and Policy number are:
Carrier. M4,S'CSTif TsYP POIICYNo.:«
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
mus anion need an, bccompleted If the permit Is fermi hundred dollars ($1011)
or less)
1 unify that In the performance of the work for which this permit is issued. I shell not
employ any person in my manneran as w become subject la the Worleri Compensation
Laws of California Dole
Applicata
NOTICE TO APPLICANT: IL after making this Ccuincau of Exemption, you alwuld
become subject to the WorknM1 Compensation provisions of the Labor Cade. you most
faMwith comply with such previsions or this peri, And M deemed rewked.
CONSTRUCTION LENDING AOENCY
1 hereby ilii^ that then las cmuwetinn lending agency for the perfurmance of
the work for which this permit W issued (Sec. 3097, Clv C.)
Lendees Name
Leade
1 «reify that I haw read this application and suis that the show Information Is
corer. I agme in comply with all city and county ordinance, and aura laws totaling he
building construction, and hereby authorize mpr<nu,iwa of oil, city to enter upon the
above-mentioned pmpeny for inspection purposes
(We) agree w new, indemnify and keep harlea the City of Cupertino Against
Ilabilides,Judgnunta,costa and expanses which may in any ray acerae again, said City
in
APPLLsequence of the ICANf UNDERSTANDS of SND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Type of Roof
Ay'-21-41_Re-roofs
SiSmanne, of App can n Dau
AZARDOUS MA'fFAl DISCLOSURE
Will de applicant or future building occupant atom or handle hazardous material
as dermad by the Cupenlno Municipal Cade. Chapur 9,12. and on, Health and Safely
ode. Sccuon 23532(a)?
All roofs shall be inspected prior to any roofing material being installed.
Yeau
/rutum_building
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Or Occupant use equipment or devlms which
it haandom air contsmtantr an dcOned by the Bay Area Air Quality Management
all new materials for inspection.
District? y
❑Yes JA__
1 have mad the ha7ardoasmawtials requirements under Chapur G95 of the Califon
niallealth& Sa(ctyCodc. Sections 23N)5, 23577 and 23331,1 understand Ntl If the building
dma not currently haw a mnank that it is my responsibility in notify the occupant of the
mqutmmenmwhichmta, bemelpriorwissuaremofa CeNRcamof Occupuey.
Signature Of Applicant Date
/itis. os—
All roof coverings to be Class "B" or better
owner ar,mna dace« Dam