04090130CITY OF CUPERTINOa'i�
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO 04090130
OWNER'S NAME:
PERMIT USUE DATE
Ighbla
CUPERTINO HOUSING
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SANITARY N0. CONTROL N0.
(650)470-4700
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I bereby affem Bad 1 Am licensed under provisions of Chapter 9 (Commencing
p
with Section 7010) of DiAsion Sof the Bass. and profeulons Code. And my Ike. is
mall (am And eBeet.3 oHb
CONDO - 1025 SQ. FT.
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Clan
-NEW
ConLic.tractor Data G'SDECL �:
Dan
O
i
ARCHI'IELTS DECLARATION
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1 underuAnJ my plAna ANII h us a ahlk Duds
Licensed Professional
OWNER- UILDER DECLARATION
I
I heathy ayfirm that I am exempt from the Contractor's License Law for the
10
following mason. (Sadun 7031.5, Business and Pmressiuv Cade: My city of county
t
which mqulres a permit to contract, altar, improve, dcmolinh, or mpalr any slreetum
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pd., to its issuance. also mquiru the applicant for such permit to nlcuigned statement
duakislicumatipunmanlloNcpmvialowoftheConlrumraLccmclaw(Chapter9
Sq. Ft. Floor Area
-
Valuation
(commencing Suction 7000)afoivision 3 ofthe Business And Pmraulav Codc)m
i $
with
that he k exempt therefrom Aad the basis fm the alleged exemption. My violation of
118654
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjccu dr, applicant as a Civil paWty, of
AM am than ftw hmalmd dolbus (5500).
0 I, u Cram of Ole pmpeny, m my mployu with wgea u thek role empemdon,
3 T 6 2 u u n—'
Required Inspections
will do Illework, and thestru°use is not amended Marfemd formic (Sec. 7040, Busircu
and Proreulom Code: The Contractors License Lew dm not apply as An owner of
property who bui IN ar Improws Duman, and who dm soh wink himself or tiuough has
own employees. provided that such improvements Am not Intended ara@red foaahe. If,
however, the building or improvement is sold within ane year of completion, the owner
builder will haw the burden of proving that he did nm Wild or improve for purpose of
sale.),
❑ 1, as owner of the property. am exclusively contructing with licensed Conkatasm as
contract the project (Sec. 7004, Business and Pmfessaans Code) The Comrutor's LI.
cave LAW dm not apply as An as m of property who builds or improve Ihmeon. old,
who contracts for such projects with A conuAnods) limmed pursuant as the Commemra
License Law.
01Amexemplundm See ,BAPCfAL1srA13An
'
Owns Dau
COMPENSATION DECLARATION
1 hereby &farm under penalty of perjury, am of the following declantiov:
haw and will maintain aCenifiamof Conselnm u15Mum for Worker,Compen-
n, As Provided (m by Section 3]00 of the Labor Code. for the performance of sic
737MWORKERS
for which this permit is tssmd.
have and will maintain Worker( Compensation Ivuounce, u Acquired by Section
of the Mbar Cade, for the performance of the work far which this permit is issued.Workers
CompensWon Insurance aNa And Policy number Am!
er. MAJU?dG 7Y -L Poliry No.:C1AAxsW.%�:3
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
trials mini led nothccompletad ifthe permlt 6 fortune hundadda0as (5100)
or kat.)
I eenify that in the perrormame of the work for which this permit is issued. l "I am
employ sny parson in any manner an As as become subject as the Warken''Compevadon
LAWS of California. Data
AppilCanl
NOTICE TO APPLICANT. IL after making this Certificate of Exemption. you should
become subject 0 the Workers Compensation provisions of the Lebo Cade, you must
foMwith Comply with such provisions or this permit shall be deemed revoked.
O
y
CONSTRUCTION LENDING AGENCY
>
I hereby anon that then is a consuuctinn heading agency ror the performance of
the work for which this Permit is issued (Sec. 3097, Civ. C.)
Lenders Nave
0
Lenders Address
Q
I certify dal I have reed this application and sum that the &tow infarmNm is
!'
Comm I agree to empty with all city and County Ordinance, and sum law, mlaling as
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building construction, and hereby aumons representatives of this city m enter upnn the
if7
ahave-menlloucd property for Impaction purlwes.
(We) Age as saw, indemnify tad keep hannheas Ota City of CupcNnO kill=
ra/3
liabilities. judgments. emu and expenses which may in any way nave against ud City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATION
Re -roofs
alwm �T e>
at
Signuum of Applic on for Data
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the m (mum building uom mlundk h&radousd al
Safety
ss dcnmd by the CupeNno MuniCip&1 Code. Chapur 9.17. and the Health and Safety
a Cupertino e. Chapter
Cook. Section 355320)7
r] Yes
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 fumm building occupant use equipment or devim which
k Wamnus air contaminants u dcflncd by the Bay Area Air Quality Management
all new materials for inspection.
Dimict7
❑Yea .rSnu`
1 have mad the haradms ma miala roqulromcnu under Clmptar 6.95 of the Califor-
nia Health A Safcty Cade, Societe; 25505.15533 And 25534.1 tunkn tand Ihulf the building
does not currently haw a tenant, But it k my responsibility as notify sic occupsnl of the
nequimmcnu which most be mel prior m issuance of Cmtincata or OccApmry.
Signature of Applicant Date
_ ` 2 or
All roof coverings to be Class "B" or better
owner or amha agent Data