04090137CITYOFCUPERTINO
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WONTRA.CUTOR INF itMATIO
BUILDING DIVISION PERMIT
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Bmu]NO ADDRESS;
PALISADE BUILDERS INC
PERMIT NO. 04090137
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY N-0 L NO.
ARCHITECT/ENOINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby ain,. that 1 am licensed under provisions of Chapter 9 (ammacing
with Section 70al of Division 3 of the Business and ProfessiuM Code, and my license is
Llmn (ores and ellen.
License Cl LIc.N
NEW CONDO -1087 SQ. FT.
Dem Cuntnctw Lis
ARCHITECTS DECLARATION
1 undcmTpJ iy plant thtlA�utt u p�M1li mM
Licensed Professional
ssionall
OWNER -BUILDER DECLARATION
I hereby alarm that I am exempt from die Contractor's License Lew for the
following reason. (Section 7031.5, Buairm s and Pmfaslons Cole: Any city Or musty
which requires a permit to construct. alar. Improve, dmmollah, m repair my strvclu ,
prior N its issuance. also requires the mpplicart forsuch permit to rile a signed statement
Sq. Ft, Floor Area
Valuation
that he is licensed pursuant to the provisions of dee Connector's lJcesuc Law (Chapter 9
(commencing with Section 70010) of Division 3 M the Bminma and Profain. Code) m
Nat he Is exempt tMrefrom and the basis for the elicited exemption, Any vlolWon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not marc than five hundred dollen ($505).
❑ 1, as.., of the property, m my employes wide wages u thetr rule compema0a,
1 2 0 0 8 4 . 0 0 Required Inspections
will do the walk. and NeattVmure ts not tuwbed moffered for sele(See.7Dm. Bushell
Aid Profada. Cade: The Committer. Lt.= Lew does oat apply m an maser or
pxepeny who build, m I.prows thereon, and who does s ash work hlmsel f ar through his
own employs., provided than such Improvements am not Intended conflicted for ale. If.
however, the building or Improvement is sold within one year of compledan, the owner.
Wittier will have the burden of proving that he did not build or Improve for purpose of
.IC.).
❑ I. a avm. a 1M properly. Am exclusively amuaning wIN licensed cmntnctas to
construct the pmject (Sec. 7044, Business and Professions Code:) The Conumtues Li-
cense taw does not apply to an manor of propeny who builds or improvm Neeson. end
who contracts for such projects with A catncmr(s) licensed pursuant to pe Contractor's
License taw.
❑ 1 am exempt under Sm. . B h P C for this ramon
Owmr Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury oro of the following decimations:
'
I new and wllI maintain a Cemil aer of Consent to self-insurefor Wmker'aCompen-
.:run, m provided for by Section 37011 of sM labor Code. for Ne performance of the
work for which Nb permit is issued,
❑ I have and will maintain Work.1 Compensation Insurer=, u sequined by Section
3700 of the labor Code. fm Nm pedorma=af the work for which this permit I, iumd.
My Workeer/s. Compensation Insurance caller and Policy number art:
Carder. 01A_Tes%C ,rlkC PoIiry NO.Cw'tdtr ,fz?ua
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thin see k. reed Act Mcompl w11Hhe permit terms. hundred dnlmn(SIM)
ar tem.)
1=nify deal In the performa.e of she work for which this Permit Is issued. I shall not
employ any Person In any manner an m m become subject the Workers' Compensation
Lawaof Celifornle. Date
Applicant
NOTICETO APPLICANT: IL after making this Certificate of Exemption, you should
become subject m the Workers Compensation prevision. of den Labor Code, you muss
forthwith amply with such pmvWnm m this Permh &hall M deemed Invoked.
CONSTRUCTION LENDING AGENCY
I that there In construction. agency for lM performance of
30Fendir.
Inc work for which this permit it issued (Sm. J(197, Clv. Cd
for which
Lmndera theme
Lcndert Address
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I certify that 1 hen rad Ws Application and ruse that HC Above Informatla it
correct. I egos to comply with all city and county Ordinanttnnd sue law mining in
building eonsimetion, and hereby autbodx rcprcxnutivu of this city to enter upon use
above-mentioned property fm Inspection purpmes.
(We) agree to new, indemnify and keep harmless the City of Cupertino against
judgments, costs and expenses which may in any Only seem against said City
In APPLICANTUNDERSTANDS of the of IAIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONs
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Re -roofs
Type of Roof
Signature of APPlic Delc
HAZARDOUS MATERIALS DISCLOSURE
WIII that applicant or future building Occupant mre mrhendle Incautious mamdai
As defined by 1M Cuponlno Municipal Code. Chapter 9. U. and the Health end Safely
We, Sada. 25532(.)7 `�y ,
❑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 aPPlinm or future building Occupant or equipment or devices which
In h4zar4oul air caterer nanm an defined by the Bay Arca Air Quality Management
all new materials for Inspection.
81rIC17
Clyne
I have read the hamn rusmAwlel.nequlmmenu underChap c,6.95 of IM Calif.,-
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HalthB SafelyCOde. Scatter; 25505.25377 and 23534.1 undmstand Iles lfden building
s not commonly hew a ten=t. Nm It it my responsibility m notify IM occupant or the
uircmemwhimmunMmel ertoissuanceofacmunmmoroc.pancy.
Signature of Applicant Date
wner
All roof coverings to be Class "B" or better
or authodn , , Dae