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CITY OF CUPERTINO+
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BUILDING DIVISION PERMIT
BUI LDING ADDRESS:
PALISADE BUILDERS INC
PERMITN .
4090141
A
PERMIT ISSUE DAT.
(
STREET
1111\179
SANITARY CO OL NO.
ARCHITECT/ENGINEER:
4:790
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONfRAC DR'S DECLARATION
lois Description
I hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70M) of Division Sof the Business and Professions Code, and my license Is
in full force xnd effect. tf D8o yb
Licenre Cle Llc.« ice+
NEW CONDO -1087 SQ. FT.
Date Cemucm, VSNdc' QurNn
ARCHITECTS DECLARATION
1 understand my plans aWhe�blic meads
i7
Licensed PP/nZdic+ui+ne-/7
OWNER -BUILDER DECLARATION
1 hereby M. Nn I am exempt from the Cmtramfa License Law for the
following Mason, (Section 7113 I.5, Business, and Professions Code: Any city or County
which Laulrn a perm0 to construct alar, improve. dcmnlBll, or repair any structure
prior In is, issuance, aim require an applicant for each Permit to file a signed nakmem
that the is licensed pmsusnl In ted Provieimts Of ted COMoscur'i Umna LAW (CMPka9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of the Businam and Pmfesiona Code) or
kat be In eumpl merehem and lee bub for the alleged cumpdon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant fon permit subjects lee Applicant oa civil Penally of
not mom than an hundred dollars ($500).
❑ L u owner of the property, or my employea with wages a theirmle compenallea,
3162008400 Required Inspections
P
will do the work, and knuucturc is act intended urofIIred foraak(Sec. 7041, Buamen
Law doInst apply an owner of
and Prefeuions Code: The Connector's License n k
. 9
property who builds or Improves therton, and whodoes uch work himselfar through his
own employees, provided that such Improvements ve not intended oroRered fm tale. If,
however, the bulldlog or Improvement is Cold within one year of mmpledan, the owner.
builder will have the burden of proving dot he did rot Wild or Improve for purpose of
tale.).
❑ L as Caner of IM property. am exclusively contracting with liceused contractee m
construct the pmjeci (Sec. 7014, Business and Profession Code:) The Contractor's Ll -
access law time not apply in an owner of property who Wilds or improves themon, and.
who contacts for such projects with a contractor(a) limmed punuanl to lee Contratufa
License law.
❑ Iameumptumer Sec ,B&PCfor tidsrcam
DwnarDate
WORKER'S COMPENSATION DECLARATION
I bereby affirm under penalty of perjury am of lee following doclanlions:
1 have and will maintain •Cenifrcak of Coeenl to seir-hourt for WorkeYaCompen-
u0on, as provided for by Section 3700 of IM Labor Cade. fm lee Performance of the
.,it for which kb Permit 1. issued.
❑ 1 bane and will maintain Workefs Compensation Instance, a required by Section
3700 of in. Labor Code, far lee performance of the weak fm which this permit Is blued.
My Workee. Compensation Insurance artier and Policy number art:
Cartier. /ar 9.3-f9?.i. Tie Policy No.:C1 �4'PO'3+•'.a
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This union need not becompleted If the permit i, froom hundred dellen ($1(B)
ser las.)
I certify that in the performance of the work for which this permit Is leaned. I shall not
employ any person in any manoran As to become mbjxuu led WMIX11' Compenalio11
Laws of California. Dae
Applicant
NOTICE TO APPLICANT: If. after making this Cediffcale of Exemption. you should
became subject to the Worker'. Com notation provisions of lee lahm Cada you moa
forthwith Comply with such provisions or kis permit hall W deemed o vekcd.
CONSTRUCTION LENDING AGENCY
I "why ken mart la tending agency fm the performmce of
sued (m .inn
rwhxffmm
' dk work for which this permit b issued (Sm. 7187, Civ, C.)
Lender's Name
Lontier'a A4drtu
1 enify mu I have read this application and tum that the above Infromatiun Is
come,, I agree to comply with all city and county ordinances and emit laws minting to
building contraction. And hereby Amnesia, representatives of thi, city to enter upon the
above-mentioned pmperty for inspection purposes.
(We) agree to ave. Indemnify and keep hamlets IW City of Cupertino agsinl
j liabilltle,judgments. costs and expense. which may in any way acme against ald City
in consequence Of mmind, of mit ncrm0.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
1*1111 2� 6
Signature afApp' HAZARDOUS MATERIALS DISCLOSURE UCa Dak
Will me applicant or future Wilding o[cupantsmre a loodlc haardous makrisi
as defined by the Cupertino Municipal Cade. Chapter 9.12. and [be Health and Safety
Cale. Section 255321x)7
All roofs shall be inspected prior to any roofing material being installed.
R7/9q
[DY.,%�
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding mcupam use equipment or devices which
I hmeodous air contaminanu as defined by the Boy AMA Air Qualify Management
all new materials for inspection.
Iarict7
❑Yes 3:51"k
1 have mad me hesardnu, material, requirements under Chapter 6.95 of the CalBnr•
rah Hcalm dI Safely Code, Sections 25505,25533 and 25534.1 undommed that If tiro Wilding
does not currently how a tenant, mel B Is my responsibility Or, nndfy the Occupant of the
oulthemenls which MOM the met prior to issuance of a CcNOcom of Occupacy.
Signature Of Applicant Date
Y-2
All roof coverings to be Class "B" or better
���—1,'
Owner or utharir agent Dow