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DRANIF�}RMATIONN
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO 04090129
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING
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SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMITINFO
ELDGO ELECTO PLUM
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby "not that 1 am licensed candor Maximum; of Chapldr 9 (commencing
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with Section 70M) afDlvWon 3 of t e Business ad Professions Code. and my license is
in full fameandeffeef A
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NEW CONDO -1102 SQ. FT.
DataCl Lle..
Data - Contract C J"g4Mr_ n•o..
'
ARCHnECTS DECLARATION
I made! Ad my Plans Iids
Licensed Professional
ER-BUIMER DECLARATION
OW
I hereby affirm that 1 am exempt from tie Contractors License Law for the
following mason. (Section 713 1.5, Business and Professions Code: Any city or county
which inquires a permit M Convect, elmr, Improve, demolish, or ¢pair any structure
prior to its Issuance, also requires the applicant for such permit an Tile A signed summent
that he is licensed pusmant to the pmvisiam of the Conuacur's License Law clummor 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
12 7 5 6 •%
that he m aempt therefrom and the basis for the alleged exemption. Any Acted= of
APN Number
Occupancy Type
Section 7031.5 by Any applicant for a permit subjects the aPpllcmt to a mvdl penalty of
not mart than five hundred dopase ($500).
❑ I'm owner ofd¢property, tar my employs with wages As their sole compestion.,
e ns
Required Inspections
winds the work,.nd thestrvemre ism, imMW oroffered forage (Sec. 7014, Business
and Pmisslav Code: The COnmwuas Liceme ds not dnot Apply m an owner of
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proarty who Wildsmimpmv thereon, and whodsauchwask himmlfortion ugh his
own employs, provided that such imp su ments tie notimended croEaM forsala If,
however, Ne building or improvement is sold within oro year of impletion, the Owner.
builder will have the buNen of proving that he did rot build An Improve for purpose of
ale).
❑ 1, as owner of the property am exclusively contracting with licensed comencmn to
construct dM moment (Sec. 7014. Business and Prefersiom Cade) The Conuamors U -
cense Law ds not apply man owner of PAopeny who build. or improv thereon, and
who contracts for such pmlccm with a cumrxcMr(s) Ilcmwd pursuant to the Consumes
License Law.
❑ 1 am exempt under Sec. . B A P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hemby affirm under penalty of perjury ane of the following declualmor
1 have and will maintain ACerefiaw of Conant m self -imus far Wmkers Compm-
sstian, As provided for by Section 3700 of rise Labor Cade. for Ne performance of the
work for which this permit is issues.
❑ 1 have and will andmam Workers Compeallon Insurance, As Acquired by Section
3700 of the tabor Code, for the performance of the were for which miss permit Is issued.
My Waaces Compensation Inman n carrier and Policy number tie:
Cense. A4Se8/a7G Policy No.: C20VZ2e.n -2o-T
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATION INSURANCE
(This Auction wed not becomplemd Miss permlt Isforane hundred dollar (SIM)
or less.)
1 certify that in the performance of the work for which this permit m Issued, I shall not
employ any panus In any mawrm as to become subject to the Workers' Compenadan
taws of California. Data
Applicant
NOTICE TO APPLICANT: If. Met making this Certificate of Exemption, you Mould
became subject M the WOher's Compensation pmvWons of the talwr code. you muR
foMwith Comply with such provisions ar this permit shall he dames rooked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that dem is a emwrwtion lending agency for tie performance of
tie work for which Nm permit is issued (Sec. 3097, Civ. C.)
Under, Name
,
IsMee. Addma
1 certify that I have mad this application and son that the Above infmmadw is
cornier, I agme It, comply with all city and county ardinAss and sero laws relating to
building construction, and hereby authoria representatives of this city to enter upon the
.hove -mentioned pmpeny for Inspection purpoas.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, Judgments, casts and expenses which may In any way accme against said City
APPL CANT UNDE STANDS AAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RECULATIO
Re -roofs
Type of Roof
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Sign O7Ap candCon DAM
HAMR15OUS MATERIALS DISCLOSURE
Will the applicant or future building amurpant atom Or handle hazardous material
As dunned by the Cupertino Municipal Code, Chapter 9.11 and the Halth and Safety
code. Section 255334)7
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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
Will the applicant or future building occupant use equipment or devil which
mit hhmnlous air inuminams As defined by the Bay Arca Air Quality Management
all new materials for inspection.
Dl.victT
1Yes u
1 have mud the hazardous materials mguimmcnts under Chapter 6,95 of the Califor-
nia Health A Safety Cade, Sectors 25505.15533 and 25534.1 understand that If the Wilding
ds not cmmntly haw a tenant, that It is my responsibility M notify tie Occupant of the
mgmmmcw. which Most Is met prior m issuance of a CertlnmtC ofOccupewy.
Signature of Applicant Date
roof
All coverings to be Class "B" or better
OwnerOnmA 6d Go Qp'0