04090143CITY OF CUPERTINO41
BUILDING DIVISION PIiRMIT('�TRe�il".OR�,.
iiti �w •
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO,
04090143
AM
PERMIT ISSUE DATE
E;
SANITARY O. ROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
hereby affirm that I am 1'teensed under provisions of Chapter 9 (commencing
with Section 70(10) or Division 3 of the Business and Prolamines Code, and my license if
In full (area antl cffen.
Licen.CI s' Lk.g 8, Bo4�
NEW CONDO -1102 SQ.FT.
Dam Curdraro :SAO dU:.J'GS
ARCHITECTS DECLARATION
-
1 mode tent my plant shall d u is records
'
Licensed Professional
O NER-BURLDER DECLARATION
I hereby affirm that I am exempt (rose W Contractors License Law for the
fallowing moon. (Section 7031.5, Business and Professions Code: Any city or county
which mquiml a permit to consumer, alter, improve, demolish, or repair any stmetum
prior it) ILL Issuance, also require, the applicant forsuch Permit to file a signed statement
Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractor', License Law (Chapter 9
Sq.
(commencing with Section 7019) of Division 3 of the Bustmas and Professions Code) or
that he if exempt therefrom and the bub for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for apermluubjects the applicant o acivil penalty of
not tame Nan live hundred delta. ($500).
❑ I, An owner ofthe property, or my employee, with wages u their into compensation,
3162008400 Required Inspections
will do the work, and Ne,wdum isnot Intended oroffered fomale(Sm. 7044, Business
end Profession, Code: The Conmcto's License Law does not apply to an owner of
. 9 P
property who build, or I mprovea thereon, end who dot tuc h work hi mself or thmugh hit
own employees, provided that such improvements arc not intended or offered for oak. if,
however, the building or Improvement i, mid within on yea or completion. she owner.
builder will have the burden of proving that he did not Wild or Improve for purpose of
,ale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
comtmcnhe project (Sec. 70". Business and Professions Code:) The Conmctor'a U.
cense law does not apply to an owner of property who Wilds or Improve, thenen, and
who contracts for such projects with a eomonuo s) licensed pursuant Wthe Contractors
License Law.
❑ I am exempt under Sea . B k P C for this reason
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby aRmt under penalty of perjury ane of the following declarations:
1 him and will amnesia a CeNOcam of Content to alf-insure for Workers Comprnm
nation, an provided for by Section 3700 of the Labor Code, for die pedmmance of the
Work for which this permit is issued.
❑ 1 hive and will maintain Worker's Compensation Insurance, At required by Section
3700 of the Liver Code, for Ne performance of the work for which this permit is issued.
My Workees Compensation Insurance tender and Policy number am:
Cartier: AIA e' 1 iC ,7" Policy No.: <24*V2S333
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This action need not be completed if tbe permh is fm one hundred dollen (girt))
or him.)
I codify that in the performance of the work for which this permit is immune, I ,MTI net
'
employ any person in any manor an As m become subject o the Workers' Compensation
Laws of CMifomia. Data
Applicant
NOTICE TO APPLICANT; IL after making this Cerd6este of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor CMe, you must
forthwith comply with such provisions or this permit shall W deemed moked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them is a construction lending agency for the performance of
_
the work for which ibis permit Is issued (Sec. 3097, Civ. CI
Lender's Name
'
Lender's Address
1 cenlfy that I have read this application and sae that the above information is
correct. 1 agme m comply with all city and county ordinances and sue laws relating An
Wilding construction, and hereby authortsa representatives of this city to enter upon the
above-mentioned progeny for inspection purposes.
(We) agree to save, indemnify and keep homers the City of Cupertino against
liabilities, judgments, cola and expenses which may in any way acme against std City
In of the his read.
APPLICANT eUNDERSTANDSr.nd.9 of tAND WILL COMPLY WITH ALL NON -POINT
Issued by; Date
SOURCE REGULATIONS.
12x, f 5 2/'d
Re -roofs
Type Of Roof
Stensen ol'Appllega ontnmor DIM
HAZARDOUS MATERIALS DISCLOSURE
Will thea applicant or future building uccupanumro or handle hmudous material
in dented by the Cupertino Municipal Code. Chapter 9.12, end the Health and Safety
Code. Section 25532(a)7
All roofs shall be inspected to any roofing material being installed.
❑Yee u
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant ata eyuipmmt or Devices whish
t hesardous air contaminants As de0od by the Bay Area Air Quality Management
all new materials for inspection.
Islricl7 �(
❑Yea,
1 have mad the Wardens materials requirements undcrChapter 6.95 of the Calre,
nice HcalN�SatmyCoM, Sections 255115,2S573 and 25334.1 undentsnd Nell the Wilding
dos nm cunomly ham a retard, that It I, my respomthility to notify the Occupant of the
requimments which mum be met prior in Issuance ofa Condemns of occupancy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
owner ver anmariy agent Date