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CITY OF CUPERTINO •3; "'
BUILDING DIVISION PERMITCQN;'12r1,4t'Uii
BUILDING ADDRESS: PERMIT NO.
PALISADE BUILDERS INC 04090146
AUKK PERMIT ISSUE DATA
SANITARY C OL NO.
ARCHITEC MNOINEER: BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
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LICENSED CONTRACTORS DECLARATION Job Description
I barony affirm that 1 un licensed under provision, of Chapter 9 (commencing
with Section 70110) of Division 3 of Inc Bwinen and Professions Code, and my liceme is
in full force mdeffem. ]�,jSO4�
LuDatemmcl - - c Ignm�aZts.yaz a�.fno�s NEW CONDO -1087 SQ. FT.
ARCHITECTS DECLARATION
1 uncle t nJ my Pisa anti ate used o hila mcnrN
Licensed Professional
O NER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Conlncum s License Law for the
following reaon. (Section 7131.5, Business And Profusions Code: Any city or county
which requires a Permit to ennnnCl, alter, Improve, demnllah, or repair any tractors,
plot m its Issuance, also requires the applicant fonuch permiuo files signed statement
that he is llanud pursuant to the provisions of the Conmmorl License Law (Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 7070) of Division 3 of the Busmen and Professions Code) or
that he I. exempt thcrefrmn and the basis for the alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit objects the Applicant a civil penally of APN Number Occupancy Type
not more than five hundred dollars (3500).
❑ I, u owner of the property, u my employees with wages o their solo computation,
will do the work, and the almclun H not intended or offered for sale (See JM4. Business 31620084.00 Required Inspections
and Prolual.ne Code: The Conuaceds's License Law dux nal apply to a owner of q P
property who builds or improves Omnon, and who doeuuch work hlmmlf or through his
own employees, provided that tach Improvements are not Ineunded oroRered for ole. IL
however, the building or Improvement Is sold within one you of completion, the owner
builder will have the burden of proving that he did not build or Improve for purpose of
saleJ.
❑ 1, as owner of the property. am exclusively contracting with licensed cantnctOn m
construct the project (Sec. 70/4, Business and Professions Cade:) The Connector's I.I.
cense Law done not to m Owner of property who builds or Improves Neuron. and
who contracts for such projects with a contractor(.) licensed pursuant to the Cutractofs
License law.
❑ I am exempt under Sm, . B B P C for this moon
Own Data
WORKER'S COMPENSATION DECLARATION
1 hereby aMan under penslsy of perjury cam of the following declaniksme
1 have end will maintain a CCNOcau of Gammon to selFbtsun for WorkefaCompen-
-0an, a provided for by Sullen 3700 of tine labor Code, for the performance of the
work for which this Permit Is issued.
❑ 1 haw and will maintain Workels Compensation Iusunnu. u required by Section
3700 of the labor Code. fm site performance of the woh for which this permit is issued.
My W~s Cntnpenudom Insurance carrier end Policy number an:
Cartier. /t1a4JCS7k: ':'9W( pllicy NO.:4f.? eQ53;301
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Mix section need mI M completed issue Permit Is forum hundred dotlars(31(D)
nr less.)
1 unify that in the performance of the work for which this permit Is Issued. I Mall not
employ any person in any manner no o m bcmme abjml to the Workers' Compenntion
Laws or California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Ccnifrcam of Exemption, you should
become mhjml to the Worker's Compensation provisions of IM Labor Code, you mull
[� forthwith amply wish such provisions m this permit M deemed revoked.
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CONSTRUCTION LENDINGAGENCY
1 herby aRhm fon there m s ed (m . 30 lending agcmy fm the Performance of
the work fes which this permit B Inwd (Sm. 3097, Civ. C.1
QLent's Name
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Lender i Addmo
I unify that 1 have read this pplication and sato that the above Information N
) &me to comply with ell city and county ordinances and vale laws mining to
building consusction, and hereby authorim representatives of this city to ever upon the
above-mentioned property for Inspection purposes.
(We) agree to save, indemnify And keep harmless the City of Cupertino against
Ilablli0es,judgments, cats and expenses which may In any way acome 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
Type of Roof
Signature ofAPPls
MATERIALS DISCLOSURE mXoraramor Date
HAZARDOUS
Will the applicant or future building mumma store or handle huodous mamdal
as dented by the Cupenlno Municipal Code, Chapter 9.13, and the Health end Safety
Code, Section 25532(e)7
❑Yes
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
Will the applicant or future building Occupant axe equipment or devices which
It hanulous air comaroimms u defined by the Bay Ana Air Quality Management
all new materials for inspection.
rinT
❑Yes
1 have read the InsaMlusmamdals mquiscments under Chapter 6.95 of then CAlifor.
1;16��_qwner
Halls At SAfmyCode, sudor 25503.25533 And 23534.1 underact thel ifthe Wilding
s not currently bees a mmnt. that is is my napomiblllty m mdfy the occupant of the
uinmcnu whim must mel prior m issuance of a CentOcate of 0[mpxmY.
Signature of Applicant Date
a .y/e
All roof coverings to be Class "B" or better
Of autho " d agent Dem