04090147CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BU ILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090147
GRK311
OWNER'S NAME:
PERMIT ISSUE DATE
E:
SANITARYN OL NO.
ARCHITECTIENOINEER:
BUILDING PERMIT INFO
BLDG PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Ienby affirm Net 1 am licensed under provisions of Chapter 9 (commencing
with Sudan 7001B of Division 3 of de Business and Professions Code. and my Ilcetu t is
in full fame end effect.
LIm.CWs effect. �gSoNy
NEW CONDO -1087 SQ. FT.
Dau Y f -e Co...PdL/On'�
ARCHITECTS DECLARATION
I undenun_ d my plan}Mall h9� Wit
iG�
Licensed Professional
OW R -BUILDER DECLARATION
1 hereby ofOnn that I am exempt from the Contractors License Law for the
following mason. (Sccdun 7(D t.5, Business and Professions Code: Any city or county
which require, A Permit m ennstmct, alar, Improve, demolish. or repair any structure
prior to its W uancc, Alto require,the applicant for such permit to Ole a signed statement
Contractor's License U. 9'
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the (Chapter
(commencing with Section 7010) of Division 3 of the Business and Professlan Code) or
Nn he Is exempt therefrom and the basis for the alleged exemption. Any vloladon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to A civil penalty of
not mom than R. hundred dollars ($500).
❑ I, u owner of the propeny, or my employees with wages we their compenuticn,
31620084.00 Required Inspections
will do site work and the structure la ntu0ntended or offend for ssu(Sec. 7044. Business
and Professions Code: The Contractors License Law dura ant apply ro an owner of
9 P
property who bulldsor Improves thereon. and whodoeuuch workhlmself or through his
own employees, provided that such Improvements are not intended oroRered forsale. It.
however, the building or Imp ..rearm is sold within ore year of completion, the owner.
Wilderwill ban the burden of proving that he did ant Wild or Improve for purpose of
tele.).
❑ 1, u owner of the property am excleAwly contracting with licensed contractors Io
..,.I the project (Sec. 7044, Business and Professorate Code:) The Contracur's Li-
ceose law does not to an miner of progeny who build, or improves demon, and
who contracts for such projects with a comin ctord) licensed pursuant the Contractors
License Law.
I am exempt under Sec. . B @ P C for tis rwon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby wilt under penalty of perjury aro of the following dwlan0ou:
1 hew and will maintain a CerdOmu of Consent to selFlnmm for Wokera Comgmt-
utitun, u provided for by Section 7700 of the labor Code, for the Performance of the
work for which this permit H issued.
❑ 1 haw and will maintain Workers Compensation Insunoce, as required by Section
3700 of the Labor Code, for the performance of the wok for which this permit is issued.
My Worker, Computation insurance carrier and Policy number am:
Arden M/Lte�T7e Twe Policy No.�{'DdM23.3JC�
'
CERTIFICATE OF EXEMPTION FROM WORKERS'
' COMPENSATION INSURANCE
(Thts section need not W completed Rine permit Is fortune hundred dollen ($1(10)
Or less.)
I «reify that in the performance of the work for which this penult Is Issued, I shell not
employ any person In any manner in u M become subject to the Workers' Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such provisions car Nle permit shell be deemed revoked.
CONSOLENOINOAOENCY
1 hereby m Inas them111Co , n lending for the performance of
s'.1
(he whim Nb pe mit is Iswa (See305D. Civ.
Mane
lander, Address
I unity Nn I have read this pplication and rete that the show Information is
correcL I ASM to comply with All city and county ordinances and tau laws miming to
Wildiag conswction. and hereby authoder representatives of this city to enter open the
ahovomentioned property for Inspection purposes.
(We) agree to sew, Indemnify and keep harmless the City of Cupertino against
liabilities.judgments, emu and expenses which may in any my swine against said City
in comegwnce of the granting of this pound.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIO
`
Re -roofs
Type of Roof
OCortSignature, ofAppjuo Ir Data
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum Wilding occupant nam or handle hanrdoua metal
as dcRwd by the Cupertino Municipal Code, Chapter 9.17. and the Health and Safety
Code, Section 75532(07
All roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
I harardnua air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
ixlrict7
❑Yee
•
IhavemW thehanrdousmaurialsmqulmmenuunder Chaper6.95o(dw Califor-
nla Health A SafetyCoM, Sudan, 21505.25333 and 25534.1 undenuntl thatifthe Wilding
data not currently how a tenant. that it is my responsibility in sadly the occupant of the
requirements which must W met prior to luuancc of a CCniResutuf occupancy.
Signature Of Applicant Date
y. V 6T-1
All roof coverings to be Class "B" or better
—�L yZl'�`,
Owner or mAhmixed egegf IDale