04090136CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
au1LDINCADDaFss:
PALISADE BUILDERS INC
PeaMlrNo04090136
149AM :
PERMITISSUEDATE
E:
SANITARY 0. CONTROL NO.
ARCHITECTaENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm that I Am licensed under previsions M Chapter 9 (commencing
with Section 7010) or Division Jof W Business and Profession, Code.and my license is
In full force and effect,
Ltunro Cl e uc.g 3 oat
NEW CONDO -1158 SQ. FT.
_
Dam c Conmurcr o B
h i
ARCHII=- SDECLARATION
1 untlenunJ my plans ,hal us uM1 sgcortla
Licengod PmfeseinnM
lir ER DECLARATION
excmp License Lew for the
1 Wmhy .(Sere el 11. exempt from the Contractor's
Ca,
moon. (Section 71H L5, Business and Professions Calc: Any city or couay
which inquires • perch contend, tile. Wpmve, demolish, re repair any Mmemro
whichFollowingre
requires IN applicant for such
pdormiucensewomet. re
Sy. Ft. Floor Area
Valuation
peau
mmmIitrcaleutgnednatemem
inn mencccnsedpunuaolmthcpmvie{nnantdre ,Bust .r'4ndNf dnnChepter9
(commencing with Scmion 7(D0) of Division J of the Busineuantl Profuunna Cndc)or
13 4 0 5 0
Nat he is exempt therefrom and she bum for me alleged exemption. Any violation of
APN Number
Occupancy'rype
Sutton 7031.5 by any applicant for a permit Objects the applicant to A civil penury of
me mom Nan five hundred dollars ($500). '
Cl I, u owner of the property, or my employee with wage u their wk=peesAtion,
31620084.00 Required Inspections
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will do the work, and the,eucom ts net intended or offered for sAk(Sec. 7044. Business
Add PromAmioe Code: The Commerce, License Law does int apply m an owner of
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Property who bulldaorimprovV silence. and whodnesaoch work Mmrufor thmugh his
Own employees, pmvided that Such Improvements art not intended reoffered for Amid. IL
however, the building or Improvement Is gold within one year of Completion, the owner•
buiMer will have the burden of proving shot he did nm Wild or improve for p urnme of
Amin.).
❑ 1, as owner of the part eny am exclusively contracting with licensed contractors to
construct the Project (Sec. 7044, Business and Profusions Code:) The Cebaetre't U -
cense law doe not apply to an owner of progeny who Wilda or improves theme, and ,
who contracts for such projects with aconmuror(q licensed pursuant in the Conmetors
License Lew.
❑ 1 am eumpt under Sec, B A P C for this rceon
Owner Dom
WORKER'S COMPENSATION DECLARATION
I hereby ,lOtm under penury of perjury one of the following dedentiom:
ave end will maintain a CeNficam ofCanunt to ulf-insure for Workeel Compere
udon, As provided for by Sutton 37M of the LaWr Code. for the perfmmmen at the
work for which this permit Is Issued.
❑ 1 have and will msimain Workers Compensation Insurance. As tequined by Section
37M of the tabor Code, for the performance or the work for which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number art:
Cartier. IN -AiE45-Policy NO.
�Fl7TFEO)CEPnONL:L �33
FROM WORKERS'
COMPENSATION INSURANCE
'
CHMS section need mol W crenPlemA Hire lurmll Is I--hundmddnnen ($]M)
MIe,4)
1 cen{fy Not in the performance of the work for which this permit is issued. I shall not
employ any pergon in any moment an u to become subject to lite WOdmn1` ComPensallan
Laws of Calif eels. Due
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, yin should
become mbjOc1 As the Worker's Compensation previsions of the Labor Code, you mull
forthwith comply with such provisions or this permit hill W deemed revoked.
CONSTRUCTION LENDING AGENCY
din es there lconstruction lending gency for the performance of
1 herebywhich
' the work for which this permit is issued (Sm. 3(197, Civ. C.)
Landcr'a No.
Landen'a Addmress
1 unify that 1 have red this application and sum that site &hove Information Is
correct. I egret 10 comply with all city and county ordinance and sate laws MIRIMS to
Wilding Constmction, And hereby sutborin repreeenalivesof ibis city m enter upon IN
d pmpc forinspectionaexpenses
:7 Shove -ms.
(We) agree to save, indemnify and keep hamles site City of Cupertino against
whichperfume,
cam and ea pcues wretch Cory in any way urns against land CTq
1 judgments, costs
edemenq
1, consequence
4 APPLICANTeUN UNDERSTANDS ANDof WILLWILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATTO S
Re -roofs
Type of Roof
✓'��"
Signature ofdp
.410famfContocki UAW
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant ams or handle heurdous material
Am defined by the Cupertino Municipal Code. Chapter 9.12, and dw Health and Safely
Cod.. Section 25572(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yea u
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
hanrdnus air contsm{name u dented by the Bay Arca Air Quality Management
all new materials for inspection.
suid7 _
0 W
I hoc mW the NYAMM smateriels requirements under Chapter 695 of the Caltfnr•
me Health h Suety Code, Secsiorn 25505,25577 and 25514.1 undulated that lfthe Wilding
deal not cmmuly he. a tenor, IN, 11 Is my m.rea milllY I. Willy the occupant nr the
requirements which MOM W met prior m mumcc Of a CerdEcne Of Occupancy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner car aulharivc eni o te
If