04090138CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N
74090138
A
PERMITLSUEDATE
SANITARY 0, CONTROL NO.
ARCHITECVENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
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1 hereby affirm that 1 Am licensed under provisions of Chapter 9 (commencing
with Section 7") of Division Sof the Business and Professions Code, and my license Is
in full force and effect. g,3 SONG
Loanse ClW �_Lia.I
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NEW CONDO -1102 SQ. FT.
Dose ConlrscrorP191-764111b0
ARCHITECTS DECLARATION
3
1 u denund my plana shall he used ..public records
Licensed Profcssi.nai
NER-BUILDER DECLARATION
I hereby affirm that I am exempt from rite Canrr.ttofs License taw for the
following mason. (Section 7031.5. Business And Professions Code: Any city or county
which requires A permit to construct, alter, improw, demolish. m repair any structure
prior In its Issuance, also requires the Applicant for such permll to file asigned statement
Comuwlurl License Law(Chapler9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 70001 or Division 3 orthe Bmineu And ProfeudnnsCub) or
5 6 •/
Nn he is exempt therefrom and the bub for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant ror a permit subjects the applicant to a civil penalty of
not more Nan few hundred d.lira (S500k
0I.uownmoftbepropeny,mmyemployeeswlNwguudalr NiOMM ewdon.
Inspections
31620084.00 Required e
wuldoNework. and the struttuatism atendWoraBeredfornic(Sm.701a,Business
W Pmresslou Code: TTe Commune, License law does net apply an an owner, of
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propeny who builds or Impaows dv:aeon, And who daenuch work himself n through his
awn employees, provided that shah imp�manu arc not intended oro@red fmsala IL
however, the Wilding or Improvement Is sold within arc Sen of compledon, Jte owtmr.
builder will have tbe burden of proving that he did not Wild m Improve for purpose of
ole.).
❑ 1, as owner of the properly, am exclualvely contacting with licensed con oche" m
construct [be projett (See. 70". Business and Professions Code:) The Contractor's LI -
cents Law don not apply to an owner of properly who builds or Improves themon. and,
who contracts for such projects with a eonlrumr(s) licamend pursuant 1. the Conuacloes
License Law.
❑ lam exempt undersea. , B & P C forthi reason
Owner Data
WORKER'S COMPENSATION DECLARATION
16 I beauty affirm under penalty of pedury oro of the (allowing declan0eru:
1 ham and will mAlnuin s CeNOmmof Com at toulBlnsum fm Workefs Compen-
nd.n, u provided for by Sado. 3700 of the labor Cade, far the performanm or the
work for which this Permit is issued.
❑ 1 haw std will maintain Wmkeh Compenutlon Insurance, u required by Section
3700 of the labor Code. for ton performance or the work for which this permit b issued.
My Worleals Compensation Insurance carrier And Policy number art:
Carden M06C,92.' Z -W C Policy No.:C�PG1[YJ� -f
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thi tenon need not W completed If the Permit Is Want, hundred dollars (SIM)
or leu.)
1 comity that In the performan n of the work for which this Permit is Issued, I Nall not
employ any person in any manner an n ut became subject to IW Warken' L'ompeNallM
Law, of Cdif oula. Date
Applicant
NOTICE TO APPLICANT: If, after making this OMIAnte of Exemption, you should
become subject to the Wnker'a COMPOMfiDn provisions of dw Lahr CMe, you most
forthwith comply with such provisions m this permit shall he deemed mwkcd.
CONSIEUCnONLENDING AGENCY
1 hereby tnrtm that there b A contraction lending gcttey for the perfnmanro of
30
tite work fur which this permit b issued (Sec. 31197, Clv. Cd
Namo
Lender's Address
1 ttnify that I have read this application and state that the show Inform Won is
I agree to comply with all city and county ordinances and Anne laws relating m
building construction, And hereby Authorize aupresentative, of this city to calm Upon the
above-mamiO.ed property for inspection purposes.
(We) agree m save, imdemmfy And keep harmbu the City of Canadian against
liabilities juµmanta, core and expenses which may In sty my acerae apiut mid City
I. cmusarquensa of the gMling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by; Date
SOURCE REGULATIONS.
Re -roofs
of ROOF
Signature OTAppli UConanscor Date
HAZARDOUS MATERIALS DISCLOSUREType
houses Occupant store handle hauNOus material
Will the applicant our re Wn
As defined by the Cupertino Municipal Code, Chapter 9,12, and the Health and Safely
CoJc, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yn0*1
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or bions Wilding occupant on equipment or devices which
It hanrdous air contaminants u defined by the Bay Ams Air Quality Management
all new materials for inspection.
mid? r-
❑ Yu
I have and the lucndau, maurialsrequlremenu underCMp crA95 of the Califm-
AiaHealthhSafetyCode,SwOom 25%5,25533am125534.l athanon thuifde Wilding
doss not currently neve A tenni. that It b my responsibility m notify the eccuFnl Of the
requirements which must mat prior m issuance or a CcntOeste of acupancy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or anthori agent Date