04090140�a
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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090140
OWNER5Q3 STEVENS GRK # 333
'S NAME:
PERMIT ISSUE DATE
E:909
ALMA &
SANITARY N /uRAL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
P
I hereby affirm that I am limiued under provisions of Chapter 9 (commencing
with Scotian 70111)) of Division 3 of the Business and Professions Code, and my license ie
Io fu Once and effmu
Lt.... Class Lio.0 g•3 Ao46
NEW CONDO -1087 SQ. 'FT.
Arnim
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Dae cmumtmr—�1S
ARCHITECTS DECLARATION
1 undmnmd m lana,hall W sed pub Ic roc
Licensed Prefeasional
OWNER-BYffSeElt DECLARATION
I hereby affirm that I am exempt tram the Contractor's License Law for the
following mason. (Section 7031.5, Business and Prafesslam Code: Any city or county
which require, a permit to construct, eller. Improv, demolish. at repair any structure
pdor at its Iuvame, elm requirm the applicant for such permit to file a signed macment
Sq. Ft. Floor Area
Valuation
that he is limned pursuant to the provisions of the Contractor' License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profession, Code) or
Nu he is exempt therefrom and the basis far the alleged exemption. Any violnion of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit Objects the Applicant in a civil Kathy of
not more than Ove hundred dollar ($500).
❑ 1, An owner of the property, or my employees with motion their mle mmpenmtlon,
31620084. OORaired Inspections
e P
will do the wait, and the structure is not Intended oroffemd mrsam(Sm. 70M. Business
and Profession, Code: The Contractor', Limnse Law dean not apply to an owner of
9
property who build, m improve, thereon, and who doessuch work hi mael f or through his
.we employees, provided that such improvements arc not intended oroRered fornale. If.
however, we building or improvement is mid within am you of complexion. the owner.
builder Will have the burden of proving Nat he did not build m Improve for Prpem of
,ale.).
❑ 1, as owner of the properly, am exclusively contracting with licensed mnbacIOM to
construct the project (Sec. 7W, Bminem and Profmslom Code) The Canua,mr. LL
cense Law dean Am apply to an owner of property who Wilds or improves thereon, and
who contracts for such projects with a contnetor(s) licensed pursuant m the Conusuers
License Law.
❑ I am exempt under See. ,B& P C for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby Air. under penalty of perjury am of the following declarations:
1 have and will maintsln aCenifiam of Consent to self -Insure for WorkersCompmx-
eelion, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this pmmh is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, As required by Section
3700af Na Labor Code. for the performantt of the Work for which this permit is issued.
My Workers Compensation Imuran, earlier and Policy number are:
Carder. A41303 -11'C Tor c P011cy No.:LRO[r7a`s..s.sp,30. �
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thin section need not he completed If the Permit Is fmone hundroddollan ($100)
car less.)
I certify that in the performanea of the work for which thin permit Is issued. I shall not
employ any person in any manner an an to become subject to the Workers' Compensation
Law. of California, Data
Applicant
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you Should
become subject in the Workers ComPcmetion provisions of the Labor Code, you must
forthwith comply with such provisions or this Permit shall W accrued revoked.
CONSTRUCTION LENDING AGENCY
1 hereby Affirm that there IS a conauacina lending agency for the perfurmanm of
de work for which Ibis permit Is Issued (Sec, 3097, Civ. C.)
Lenders Name
Lender's Address
1 modify that 1 have read this application and ,tam that the Alban Information is
Manuel. l agree to comply With all city and county ordinamw and state lawn relating e
building construction, and hereby authmbe representatives of thin city to enter upon the
above-menduned properly for Inspection purposes.
(We) agree to are, indemnify and keep harmless tire City of Cupertino against
liabilities, judgments, coats and expense, which may In any way scene against asid Cily
Inconsequent: of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by; Date
sOURCa REOULATI
Re -roofs
Type of Roof _
Signature ofA crvCanw or Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupant emus or handle havardous material
as defined by the Cupertino Municipal Code. Chapter 9,12, and the Health and Safety
Cada, section 25532(a)7
❑Ya
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
Willi the applicant at future building mcupant use equipment or devices which
It hazardous air contaminants as dofinod by the Bay Area Air Quality Management
all new materials for inspection.
uic1T
❑ Yes
I have nand the hanrdous materials requirements under Chapter 6,95 of the Califor.
nia Health & Safety Code, Section 25505,25533 and 25534.1 undernmd that if the Wilding
dean not currently how a errant, that It is my mspomlMhly to nobly the occupant of the
requlmments which must met pdor to issuance all Ccmficate of occupancy.
Signature of Applicant Date
All roof coverings to be Class 'B" or better
Owner or authorizodagem Date