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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT.yoN:Jt.IC°[.QIZzIN'QRMA'�IONp;
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090133
OWNERS NAME:
PERMITLSSUEDA7E
SANITARY No. A OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O O
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby situ, that 1 am Returned under provision. of Chapter 9 (commencing
with Section 7") of Division 3 of the Busirleee.nd Prounion, Cade, And my license is
in full force roti effxd, Q��A4�
Llcana lain ue.a
NEW CONDO - 1106 SQ: FT.
Date Contractor 0941,I5/iii2s, sir.
ARCHnTCTS DECLARATION
Iundemmd my Alam shall aspic 1
Licensed Professional
11191.,UILOHR DECLARATION
I hereby of iren that I am exempt from the Cnmrenor. License Lew for the
following mason. (Section 7(131.3. Business and Professi Code: Any city or county
which requires a permit to construct. alar. Improve, demolish, M repair any structure
prior m its June=, also requires the applicant for such permit to Ole asigned statement
Cormae License LAW (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant in the provisions of the u'.
(commencing with Section 7000) of Division 3 of the Bu swan and Profeeun. Cade) ser
that he It exempt therefrom and the basis for the alleged exemptlon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penalty of
not more than RDI hundmd dollar ([500).
❑ 1, As owner of the property, or my employes with wages u their sole compensation,
31620084.00 Required Inspections
P
will do Le work and lheamucncre Is= imundedor offered (crisis (Sm. 7044, Business
end Prafessiona Code: The Communes Liana Law does not apply to m owrer of
q
propeny who bas Idsm Improvms thereon, and who doe.soch work himselforthrough his
own employes, provided that such Improvements arc not indeed oroffarcd forasls, If,
however. the building or Improvement Is gold within oro you of cmnpledon. Ne ower.
builder will have the burden a proving; But he did not Wild M Improve for purpose of
sale
❑ 1, as owner of the property. am taclusivaly coninuing with licensed ronmecncn in
construct the pmject (Sec. 7044, Business and Professions Cade:) 704 Commute. LL
come Law does not apply to on owner of property, who Wilds sir improve, shown, end,
who contracts for such projects with a contnemr(Q licensed pursuant to the Commences
Lkene Law.
❑ 1 am exempt under Sec. , B k P C far this reason
Owner Dun
WORKER'S COMPENSATION DECLARATION
1 hereby afarm under penalty of perjury one of the following declarations:
Me and will maintain a CMHEMM of Consent to elf- n.um for Workers Compen.
cation, as provided for by Section 3100.f the Labor Cade, for the performance of son
work for which this permit is iuved.
❑ 1 have and will ELLE Weekees Compensation Insurance, as required by Section
3700 of the IuWr Cade. for the performance of Ne work for which this Permit is word.
My Worker, Compersubm I.ca. canhu and Policy number am:
carder. MA6ea7:4z %U!_ Policy NEE.:lri l.IQ'g�wi 'O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
'
(ITU section need not W completed If the permit i. fmonshundreddollan ($100)
M lets.)
1 canify Net In the performance of the ,it for which this Permit I. lusted. I shall not
employ any person in any manner an as to become subject tmhe Workers' CompenasBon
LA. of California. Deas
Applicant
NOTICE TO APPLICANT: If. after making this Cen ricau of Esemption, you should
become subject to the Workers Compcmation provisions of the Labor Code. you on
forthwith comply with such provitious or Nis permit hall he deemed revoked.
1 due ft.UC170NLENDINGAGENCY
1 hereby affirm Nee its comuMdnn lending gcMY for Ne pcdormuue of
Nu
' the wick for which this permit Is woad (Sec. 3091, Civ. C.)
Lando. Name
Lender. Addreu
i I certify that 1 have mid this application and tau that the above Informalion 1t
t cannot. I gree to empty with all city and county o dinemes and Mu laws rtlsting nc
Wilding construction, and hereby authodve representatives of his city to enter upon led
ahovomemioned property for Inspection purposes.
(We) agree to save, indemnify and keep hmnlau the City of Cupertino spaWt
i liabilities, Judgment, cam and expenes which may In My way accuse against Mid City
In conequence of the Scenting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATION
1017, -
Re -roofs
Type of Roof
ComoscomSignature ofApplic Dau
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future Wilding omupanbncre or handle hnudous material
As de0ned by the Cupenlno Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yoe
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building occupant use equipment or devices which
I havArdoul air contaminants M defined by the Bay Area Air Quality Man+4emem
all new materials for inspection.
I[Irict7 _ I
I have reed the havardaus material, repAremenu underChapter 6,93 of the Califor-
niaHealth A, Safely Coda Sections 25505,25533 and 25534.1 understand that If tho Wilding
dom not currently hove a Earned, Nat it l, my MFORSIMMY to nul l'Y the Mcupant of Ne
mquircmamit which must W met poor in inu m or a ceNOcam of occupancy.
Signature Of Applicant Dale
Z-,,_
All roof coverings to be Class "B" or better
Owncrnr MN rode enl Wu