04090134CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUIL DING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090134
A9amiPTEVENS rRK # 317
PBRMITL"SUEDATS
E:
SANITARY OL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MEC"
l� l� O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm IMI I am licensed under provisions of Chapter 9 (commeneing
with Section 7") of Divlrioa 3 of the Business sad Profcuions Code, and my license is
,
in full force and effect` p,3t3oH6
ucen,eel Lk..
NEW CONDO -1158 SQ. FT.
Dae camranOr' .JNe� .sea«
ARCHITECTS DECLARATION
1 undemand my plena shall BC uaW u pIW IessnWe--
LlcensedPmfeuional
OWNER -BUILDER DECLARATION
,
I hereby affirm that I em exempt from the Contractor', License Lew for the
following mason. (Section 7031.5, Basindla and Professions Cade: Any city or county
Which requlfos A permit to connmcl. alter, Improve, demolish, or repair any at ICLUM
prior N its Issuance, also requires IW applicant for such Permit to Ne a signed statement
LA.
Sq. Ft. Floor Area
Valuation
Nat he is licensed pursuant to the provielnns of the Contncmr'a License (Ch iner9
(commencing with Section 70D0) Of Division 3 of the Business and Professions Code) or
that he 4 exempt Lit mfmm and the bub for the alleged exemption. Any violation Of
APN Number
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applicant m a civil penalty of
not more Nm five hundred dollars ($5001.
❑ 1, as Owner of the property, a my employees with wages As their sole compensation,
31620084.00 Required Inspections
P
will do the wok, and the suucmre i, Put Intended or offered fee W. (Sec. lou. Business
and Profession, Code: The Charlene, License Law does not apply to an owner of
q
propeny who Wilda or Improves lhemen.and whodoeuuch work himselforthrough his
own employees, provided that Such improvemenuare not Intended aoffend for sale. If.
however, the building or Improvement Is mid within one yeu of completion. Ne owner.
builder will lura the burden of proving that he did not Wild Or improve for purpose of
sales.
❑ 1. a, Owner of he property, am exclusively contacting with licensed contractors to
consume, Sha project (See. 7044. Business and Professions Coca:) The Contractors Lt.
CO. LAW does nm apply m an oWnef of pmperny who Wilda or imp.. NLRM. Nd,
who contacts for such pmjecu with a eomrxear(O licensed pursuant m the Contractor,
License Law.
.
El am exempt under See . B As P C for Nb season
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby afOml under penally of perjury one of Ibe following declarations:
have and will maintain a CerifiUe of Consent to elf-imure for Workers Canpem
wlon. u provided for by Section 3700 of the IoW, Cade. for the part... a of the
work for which this Pemlit ie ivuM.
❑ I nave and will maintain Worker's Compensation Insurance, u required by Section
3700 of Lha labor Cade, for the performance of the work for which Nb Permit is Issued.
My Workers Compensation Inman carrier and Policy number am:
carrier: Xs' Of3x`�J%C IL C Poliry No.:1-AO6e.1.125 O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thio see,ion need not Ncampleed time permit Is forone hundred dollars (51(10)
or lest)
1 Unify Nm In the performance of the work for which IMO Permit Is Issued, l shall not
employ any Perron In any manner m As to become subject o the Workers'Compensalion
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making this CenlOcae of Exemption, you should
become Subject to the Workers Compensation previsions of the IaMr Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDINGAGENCY
ending agenry for Ne perfurmanU of
1 hereby Nn Nero In construction puny
whaffirm
30
the wud for which this Pertn11 I, Issued (Sec. J097, CO. Cd
Lenders Name
'
Lender, Addmas
1 1 Unify that I have read this application and sue that the above Information Is
t UITCM l ISR to comply with all city and county ordinuwss and Sam laws relating in
Wilding construction, and hereby mmorim Rprosemuthes of Nis city to enter upon Ne
1 above-mentioned propeny for inspection purposes
(We) agree to save. Indemnify and keep harmless the City of Cupenmo against
j liabilities. judgments, cuts and expense which may in any way socrus against mid City
In consegucnce of the Starting of this permit.
i APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOU9ULATIONS, /alp_
2-2/-61
Zi�flL1Kcdem
r1yAf19
Re -roofs
'Type of Roof
Sign.,. AtApplican Oren T or Dam
AMDOUS MATERIALS DISCLOSURE
Will the applicant a future building Occupant tore or handle harudous material
AA defined by the CupeNno Municipal Code. Chapter 9.17. and the Health and Safety
Code, Section 3553]/,)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Ye o
If a roof 15 installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or fuss. b ilding occupanl use egulpme t or devices which
harardnus Air contaminants u defined by the Bay Ana Air Quality Management
all new materials for inspection.
nrict7
❑Yes u
I have rcW Nehuemres meurlelareyulrcmenu under ChePer A.95 of the Califon
ala Health is SafdyCode. SUi 355115.35533 and 25534.1undemand NatlfNe Wilding
does nm Urecruly hese a unem, Nat II is my re,mems ably m notify IM uU.panl of Ne
mguimmcnu which must W mel Pnhrm iamance Of CCNECAW Of Occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner. amhorir a em Q�/