04090145F G
U
CITY OF CUPERTINO
Wrt,I t I + -777=4,
BUILDING DIVISION PERMITcUNTI2A.CrfURIUA'IQi`I,'z
BUILIM O ADDRESS:
PALISADE BUILDERS INC
PERMS Nis.
04090145
A_323
PERMITISRJEDATE
12
111Q\A `10 4:79G
SANITARY ROL NO.
ARCHORCTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
o P
1 hereby affUm Thal 1 am licensed under provision, of Chapter 9 (commencing
with Section 7") ufDivlslon 3 arrive Business and Profcuinu Cade. and my license is
infull force sau lsct. AaS�L
L .Oct Lm.g A�� -
NEW CONDO -1087 SQ. FT.
_
Dam Comrum •,T
ARCHITECTS DECLARATION
i nna,na� u g ., pnmlo rcawm
Liccned Pmfossionel /
DECLARATION
Oat
I am exempt from smog Licence Law for the
1 hereby .Niece that 11. exempt from me
ion Cadc: Any city sur county
Following (mann. 71alae, and essio
w, de ri repair Mrocmro
(anti t common, Impmw, demolish.
which requiroa a permit
reuiheaim(, (. ed
prim m its issued,,lass re the applicantan,of for each permit m rite.
Law
Lkense Law
Sq. F[. Floor Area
Valuation
(Chmmem
to IN w (Chaprer9
that hchllttlMW pursuant to the pmvialon of the Cantrutw',
(commencing with Section 7000) or Division 3 of IM Buinessand Profession Code) or
out be, is aumpt therefrom and the buts for the alleged ewnp ion. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit Objects the appliCant Io a civil pertslty of
not more than five hundred dollars ($SW),
❑ I, u owner ofthe properly, or my employees with wages at their Ole compensation,
3162008400 Required Inspections
will do the work, and the,mucium is notimended ornaered foliate (Sm. 7044. Business
er License Isdoes not apply an owner of
and Profaulons Code: The Commencer m
. 9 P
property who bu Ilds w i mprows themon, end who docuuc h work hi mself w through his
own employees, provided thMsoch Improvemenuarc not Intended oroacred fwaals, if,
however, me building or Improvement Is sum within ON year of completion. the Owner -
builder will law Lha burden of proving mu IN did not build w Improve for purpose of
talc.).
❑ 1, a owner of the property. am exclusively contracting wim licensed Ontrumn he
consumer the project (Sec, 7044, Business and Professions Code:) The Consumes Lb
cents Law does not apply to an owner of property who wilds at Improves meRM, and,
who contracts for such projects with a contractor(,) licensed pursuant to am Communes
License Law.
❑ I am exempt under See. ,B k P C for thin rcamn
OwnerDam
WORKER'S COMPENSATION DECLARATION
1 hereby,farm under penalty of perjury ON of the following declanrbm:
ave and will maintain a CertlRa'ale of Consent to neff-mUrc fur Workeea ComPCD
s on, u provided for by Section 3700 of 0th Labor Code, for the performance of the
work for which rob pemlit h Iuucd.
❑ 1 have and will maintain Workee, Compensation Insurance, u Iequlred by Section
3711 of the Labor Code, for me performance of the work for which this permit is Iuucd,
My Wodees Compensation lasuonce tinier and Policy number art:
Carder. /g'rALTe-3%iC TV< Policy NG.:�.��.S33r`v
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This metim need not sue completed Hthe permit B forone hundred dollgs($1 W)
ter lest)
1 certify that In the performance of the wnrk for which this permit is issued. I shall not
employ any person In any mune( an u an become Object to the Workers' Compemurlon
Laws of Celifomia. Dam
Applicant
NOTICE TO APPLICANT: If, after making rob Cer00esm of Exemption, you should
become ,object in the Worker', Compensation provisions of the Law Code, you mug
' forthwith comply withsuch provision Or this Permit Mll be dermad revoked.
CONSTRUCTION LENDING AGENCY
i I herebywhin thi that them les construction agency l'nr the performanceof
3nlending
' theLe work for which this permh h Issued (Sec. 3097, Cl, C.)
Lmdcr'a Nunc
Lcnder'a Address
j 1 certify mat I haw Ind this application and Oma that the whom Information Is
' cmnecL I agree to comply with all city and county oNinneund Mum law, mlaling to
building emmoetimn, and hereby amended repressmows of this dry to enter upon the
ahove-mentioned property fur inspection purposes.
(We) agree to use. mdeminfy and keep homeless the City of CuPenino against
j Iiabllitice,judgments, cuts and expenses which may In any way acme against aid City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
h' 2P0.
Silmaro of Appl ntrut Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII the applicant or future Wilding occupant Marc or handic hauNous mamd,i
an de0ned by the Cupertino Municipal Code. Chapter 9.17, and IN Health and Safety
Coln. Section 255324)7
❑Yes
All roofs shall be inspected prior to any roofing material being installed.
in
If a roof is installed without first obtaining an inspection, I agree to remove
ent er Talon building occupant use equipment or devices which
WIII the aPPlicenter
hawdou rola conlaminnts u tic0ned by the Bay Arca Air Quellly Managcmcnl
all new materials for inspection.
atflCl7
❑Yes 3
I hive real me Itsnrmws materials requirements under Chapter 6.95 of the Cali fon
RIM Health A SaferyCude. 9eciiwts25305,25533 anti25574. 1 underhand that ifthe Wilding
tins not currently hum a mnanL that It Is my responthility se Iwtily tiro Neupent of the
requirements which must eemet prior toinu ttoracertificate orO'�rumey
Signature of Applicant Date
A .2 .
All roof coverings to be Class "B" or better
Owner orewhorivedagenl- Dateon—