04090118a
U
G
BUILDING DIVISION PERMIT
PALISADE BUILDERS.INC
ARCHITEC (ENGINEER;
that 1 Am licensed under provisions of chapter 9 (commencing
ivision 3 of the Business and Professions Code, and my license is
NEW CONDO -1487 SQ
1 homey AMM that I am exempt from the Contractor's License Law for Ne
following mason. (Sudan 7031.7. Buslness and professions Code: My city Or comny
which re uiru a vomit of construct. altar, improve, demolish, at repair any kmetum
prior to is issuance, Alto requires Oe applicant forsuch permit to Ole a signed moment
that k is licensed pursuant m Me pmvitimu of Me Canummri I3anse law (Chapter 9
(commencing with Section 78)0) of Division 3 of Me Business ad Profeuiav Cade) m
that he Is exempt the.f.. and the basis for the alleged cxempMoa. My violation of
Section 7031.3 by any applicant for • permit Objects the applicant In A Civil penalty of
AM mart dun five hundred dolsn (5500).
❑ 1, u owns of the property, on my wployw with wages as thea ms CompensaMan.
will do Me work, and the struCmre is not inunded aronamd fm aces (Sec. 7041, Business
and Professions Code: Th Convenor's Lkena Law does Am apply m an owner of
property who bulldam Improves thmmn,and who doessuch work himselfor Waugh his
own employees, provided thksuch improvemensam not imendW maffesed fu We. If,
however, the building or Improvement Is Old Whin one you ofeempletion, the owner.
Wilder will have also Arden of proving that he did net build a Improve for purpose of
Ale.).
❑ 1, As Owner of the Property am exclusively contracting with licensed conummn he
mnswct Ne pmject (Sec. 7044, Business and Professions Code:) The Contractors Li-
cence law data not apply to an owner of property who builds or improves Neuron, and
who contracts for such projects with a eantretmr(s) licensed pursuant to the Contracmrs
License Law,
EJ I am exempt under Sm. , B A, P C for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby &Rion under Nasky of pesjury aro of the following declmtiaMr
1 have and will ..!main •Call of Consent to self -into. far WmIcesCompen-
Ation, as provided for by Section 37M of the Inbar Code, for the performance of the
work for which this permit is Issued.
❑ 1 Mw and will maintain Workers Compensation Insurance, as required by Section
3700 of Ne labor Calc. for the earformanceaf Ne work fm which ths permit s Issued.
My Workers CompenAtion lnsurana canner and Policy number m:
Cartier. MASC_*Zk 74.0 Policy No.: Lw7dec Q.25230
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ons motion head not be Completed If Me Permit is fmone hundred dollen (SIM)
Of tats.)
I Certify that In the performance of the work for which this permit is Wood. I shall not
emplay any person In tiny manner O As m become subjul m Me Workes'Comperw8on
Laws of California. Dae
NOTICE TO APPLICANT: IL after making this Certiliesta of Exemption. you Mould
become subject ro the Workers Conformation provisions of Ne Labor Code, you mum
forthwith Comply with such provisions or this permit shall b, deemed .wad.
CONSTRUCTION LENDING AGENCY
I hereby of Ion that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097. ON. C.)
Under's Name
Lender's Address
I certify that I haw mad this application and sum that the $Ave information is
coma 1 agree to comply with all city and county ordinances and cuss laws talking m
building convection. and hereby authorise representatives of this city to enter upon Ne
&Ave -mentioned Property for inspection purposes.
(We) agree an Ave, indemnify and kap harmless the City of Cupertino Against
liabilities, judgments. emu and expenses which may in my way memo against said City
WILL COMPLY WITH ALL NON -POINT I Issued by: 11
Will the applicant or foto. Wilding =upset mom m handle huardans material
As defined by Me Cupertino Municipal Cade, Chapter 9.17. and Me Health and Safely
Cade, Section 35532(a)7
Oyu ]QNu
Will Mm applicant or future building Occupam use cyuipment or devices which
v hauteur, air contsminsnts As defined by Me Bay Area Air Quality Management
❑ yes 1-4211u
I haw road the haundous material
nia Health h SaictyCode, Sections 35505,
does rot currently haw a tenant, that it f
requirements which most Nip et prim of
Re -roofs
Type of Roof
090118
Femmrr MUL UNIH
Job Description
FT.
Required Inspections
Date
CONTROL
172135
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