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CITY OF CUPERTINO
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I40RMATTUN *-
BUILDING DIVISION PERMIT
C01 -11
BUILDING ADDRESS:
PALISADE BUILDERS INC
P"`"Icb4090115
OWNER'S NAME:
PERIM ISSUB OATS
CUPERTINO HOUSING
NE:
SANITARY 440. CONTROL NO.
(650)470-4700
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
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Job Description
I hereby afRem that 1 un licensed under provisions of Chapter 9 (Commencing
with Section 76m) arDivision 3 or 0te Business and Prolusions Code, and my license is
immtrnneandercn
Clw Lk. Y
NEW CONDO -1506 SQ. FT.
Dam Contranar �: 4
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ARCHITECT'S DECLARATION
I undewny�`s eha1115ys u publtora<ordf
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Licensed ftmistoul
OW I ER -BUILDER DECLARATION
I hereby affirm that I an exempt from the Conusctort UCCnm Law for the
fallowing moon. (Section 71015, Business and Profusion, Cade: My city or county
which requires • permit in co mwet alter. W prove, demolish. or repair my unit ure
prior ro ins Wwnce. tlw nquims the applicant forsuch permit to flit signed mtement
Ft. Floor Area
Valuation
Wt a is licensed purstanto to provision, of the Common's Uceuc Law (Chapter 9
Sq.
(commencing with Section 7000) of Division 3 of the Businwand Profusions Crate) or
$174334
that he k exempt therefrom and the basis for the alleged exemption. My violation of
APN Number
Occupancy Type
Section 703 LS by any application for a permit subjects the applicant to a civil penalty of
not more than Ow hundred dtllan (53007.
❑ I, u owner of the property, or my employees with wages as their sola compensation,
1 b U U 8 4 U URequired Inspections
will do to work. and thestucture tram inknded oro@redf ash.(S.C. 7044, Business
and Profusions Cade: The Canbano's License law does nal apply man owner of
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property who builds or improves Damon. aM who doesswh mark himseIf or through his
own employees, provided that such improvermaxi not Intended aro@red fornk. If.
however, the building or improvement is mid within one year of completion, the owner.
builder will have the burden of proving that he did nal build or Improve for purpose of
ask.).
❑ 1, as owner of the Property, am exclusively comrmstal with licensed Conumton in
construct the prejen (Sec. 7044, Businesa and Professi«a Code:) The conbacmre U.
cense law dans not apply to an owner of progeny who builds or improv thereon. and,
who Convects per such projects with a tenmetor(s) licensed purwant tome Convacmrs
License Law.
0 I am exempt under Sec ,BA PC far this moron
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby arNm under penalty of perjury one of the following decluatlons:
1 have and will maintain • Cenifrcate of Consent to self -i -m n f« Workers Compm-
we'.., as provided fm by Section 37M of the Labor Code, far the p ntimm me of the
work for which this permit is armed.
❑ 1 haw and will maintain Workers Compensation Inwnnce, as requited by section
3700 of the labor Cade, for she performance of the work for which this permit Is Wised.
My Workers Compensation Insurance Cartier and Policy number are:
Cartier. ANSfiea7:G PolicyNa.;eai0C`22S 1310,6
CERTIFICATE OF MEMPOON FROM WORKERS'
'
COMPENSATION INSURANCE
mels section reed not be Completed if Ute permit is f«onehundraddellarninI f
or Im.)
1 Certify Not In me perrortnanee of the work for which this permit Is issued. I mall not
employ any person In my insurer an u to became subject in the Workers' Compensation
Laws of California. Data
Applicant
NOTICETO APPLICANT: If, after making this Certificate of Esemplum. you should
become subject to the Worker's Compensation provision, of the Labor Code, you must
foMwith comply with such provisions or this permit &hall be deemed evoked.
CONSTRUCTION LENDING AGENCY
I thereby affirm that there Is a ecumandos lending agency for the performance of
the work for which this permit is insmtl (Sec. 3097, Civ. C.)
Lender's Name
lander. Mdew
I certify dust 1 have nand this application and mm this W &bow infomt W un k
torten. I agree to comply with all city and County ordinances and rote law relating to
Wilding cansmmton, and thereby wthorire representatives of this city to cnm upon the
ahow-mention w propeny for inspection purposes.
(We) ague or ave. indemnify and keep amity the City of Cupertino against
liabilities, judgments. costs and Cxpemu which may In any way taxes: all Wit City
In cogusn,e of the granting or this permit.
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I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
,
SignawrcefApplicm tor Dan
HAZARDOUS MATERIALS DISCLOSURE
WIII applicant or forum building e,C «handle material
Health a
u defined by due Cupertino Municipal Code, Chapter 9.17, and tiro Health and Safety
y t hapte 9,1
'
Cede, Section 233320)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yu 01(u
If a roof is installed without first obtaining an inspection, I agree t0 remove
.Will the IPPIICML or future building occupant use equipment or device which
It harudous air conaminmu as defined by the Bay Area Air Quality Management
all new materials for inspection.
wict7
Yes
I have mad Ne haralloa materials oxfoomments underCapter 593 of the Califon
nuH.10&SaretyCode.Secdau73303,73333u42333/.1wdcrumdauifdu building
dans not currently haw a unit this It u my responsibility m unify the excupant of the
requirements which most be met prior to instance of a Ccnificate of Occas grey.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
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Owner «.« ra &gen,