04090135Zoe
d�
a
0'7
0.77
%Fa%d
3�
U
CITY OFCUPERTINO
z
Q
v~N.,
Q
z
Q
Fcorrect,
U
Lk)
y
•= OR TN'C1tMti."C q
BUILDING DIVISION PERMITCONTIir1
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090135
A
PERMIT ISSUE DATE
SANITARY OL NO.
ARCHIECTIENOiNEER:
BUILDING PERMIT INFO
BLDG PLO MECH
O 1�
LICENSED CONTRACTOR'S DECLARATION
Job Description
Ihenby that1am Incensedunder
dP,ofeuofCW&.9(commencing
wish Sctlon ]O(Ilp of Dlvidon 7 of Na Bminux apnd Profeuium Credo, and my Ilcemc la
)or
In full tone and effect. 16 8'3$0 4 6
License Con nemr A JSN tlr
NEW CONDO — 1158 SQ. FT.
Dale eO�wr
ARCHITECTS DECLARATION
I undo,4dmy ponsila c�iblic wood,
Licensed Pad'esatnnsl
.
OI NEm RATION
I hereby .Elena that 1 exemDER m the License Lew for the
exempt from the Conioses
.
Professions Cade: Any tiny or county
maso 703 1. Business and Ca
following mama.
de
which requires a pclmin In construct, dtem Improve, dcmnlish. or repair my structure
onalt t sir t, improve.
pilar III IB Issuance. Also requile[ the aPPIICMI for such permit to file A signed statement
Lhcnm Law 9
Sq. F[. Floor Area
Valuation
that he is licensed pursuant m the provision of the Contncble, (Chapter
(commencing with Section 7000) of Division 7 of do Business and Professions Cam) or
slut he is exempt therefrom and the bull for tate alleged exemption, Any violation of
APN Number Occupancy Type
Section 7071.3 by Italy applicant for a pelmh subjects the Applicator to a civil Penally of
not mon Nan five hundred dollars ($500}
.
❑ I,uownoraflhopropeny.mmyemploywwithnguuthcirroleeampevmlon,
will do the work. and the nonuse Is notIntended oraRertd fmaak(Sec. 7044, Business
31620084.00 Required Inspections
sed Professions Cade: The Commune, License Low don Out apply m An owoe of
property, who Wlldaar improves demem.and who dws,mh work himselfor Uuough his
own cmployeu, provlded Oataveb Improvement art notinmeded moRered ferule If.
however, the building or Improvement Is mid within an year ofcompletion, the owner
bulidee will ". the burden of proving that he did not build or Improve for purpose of
AMC.).
❑ 1. as owner of the property, am exclusively contracting with licensed contncmn m
consumer the project (Sec. 7014. Business And Prefnsto r Coda) The Com�mmM1 Li-
cense Taw dos not m an owner of property who Wilds or normal themon, rod,
who contacts for such pmjocts with a conmctons) licensed pursuant to the Conmactoes
Lkanu Law.
❑ lamnomptunder See. ,B&PCfortNs.AAM
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby AOhm under penalty of perjury one of the follnwing declarations:
ham and will maintain • CertmOcam of0meenl Io rola-iuun for Wml,cesCompen-
udon, u provided far by Section 7700 of the Lobor Code, for Ne parfonnantt of the
walk for which this permlt Is issued.
❑ 1 haw end will maintain Workcb Compensation Insurance, u required by Section
3]00 of the Labor Code, for the pedormmtt of the work fa which this permit is mutual.
My Workeeg Compensation Imunnce canis and Polity number am:
" 7
CArlier. H1AJeJT�C %f/CPoluy No.:g,.d0(13d�-3
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This sectio Meet W complated role IemII Is Funme hundred 01). (SIM)
ser Int)
1 unify that In the performance of the work for which this Permit Is Issued, I shall not
employ any pconn in Any manner m u be became object the Workers' Compen t o t
Lows of Catifomma. Doo
Applicant
NOTICE TO APPLICANT IL after making this Cer ifca a of Exemption, you should
WCOrlte subject to the Worker's Cmarenaation provisions of the Labor Cede, you mull
fonhwmth comply with such provisions or this permiuhall W deemed revoked.
CONSTRUCTION LENDINGAOENCY
1 horny that there b construction lending agency for the performance of
cRrm
30
this work fur which this pcnnit is Issued (Sec. 3097, Clv. Cd
s
Lender's Name
.
Lender's Address
1 unify that I how and this application and slam that the allow Information is
1 agree to comply with all city and county ordinances and saw low, relating m
building convection. And hereby suthodm repremmanives of this city to enter upon the
Ahovmmenliuned property for inpecdon purposes.
(We) Agree to sew, Indemnify and keep harmless the City of Cupertino against
Ilabllitiu, judgmcnu, cosi And expenses which may in any way sten Against AddCity
in cortsequoe of tho gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCEREGULATIONS
Re -roots
Type of Roof
a— A
Signemrcof Applin omracmr Dau
AZARDOUS MATERIALS DISCLOSURE
Will too Applicant or future Wilding occupant Mom orhandlc huardoo material
As dented by the Cupertino MunicI I Code, Chapter 9.13. and the Health and Safely
Cade, Section25572(a)7
All roofs shall be inspected prior to any roofing material being installed.
p Ye.
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
Aae.Nous air comou";ants defined by the Bay Area Air Quality Management
all new materials for inspection.
Mricl7
❑Yes u
I have reed the huardoa materials requirements under Chapter 6.95 or the Califor.
ria Health At Safety Code, Sectors 8303, 23577 and 25571.1 understand! thulithe Wilding
docs not currently how a tenant that it is my responsibility m notify the Occupant of the
requirement which must Wm sir in issuance of a Cerancam of occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
ownea ar amnnrized set D/