04090148CITY OF CUPERTINO,
Tl+`7alvA..'i<,al-t�,.
BUILDING DIVISION PI•;RMITCC)1V,TRA.'Qi
BUILDINGADDRESS:
PALISADE BUILDERS INC
PERMITN
$4090148
WaZ$7EVENS CRK # 211
PERMITISSUEDATB
129,12
SANITARY CONTROL NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
O O
LICENSED CONTRACTOR'S DECLARATION
late Description
P
I hereby affirm that L em licensed under provisions of Chapter 9 (commencing
with Section 7007) of Division 3 of the Business old Professions Code, And my license is
infull to= and effect.
uc'me Cl Lie.« D-�C+��
NEW CONDO -1087 SQ. FT.
De@ -2 O Conlr¢br PF#14AAL L,I/QO"$
ARCHITECTS DECLARATION
I sande u J my prism shall use u4ALp MI reLrlpptds
%Yes Kms_
Licensed Professional
OWNER -BUILDER DECLARATION
1 hemhy affirm that I am exempt from the Contractor'& License Law for the
following moon. (Section IID I.S. Business and ProfeWam Code: Any city or county
which require a permit In construct. stun Improve, demolish, or repair any structure
prior In it, issuance. also requires the applicant for such Permit 10 file ulgned statement
Sq. Ft. Floor Area
Valuation
that he is licensed punuam m the provisions of the Conmctar's License Law (Chapter 9
(Commencing with Section 7000) of Division 3 of the Business and Pmfcuinns CMA) or
that he a exempt Nuefrom and use hub for W alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for A pennluubjects as Applicant to a civil Penalty of
not mart than five hundred dollars ($500).
I, AS owner of the property, m my employees with wages AS their sole compensation,
31620084.00 Required Inspections
e
will do the work, and the suucom is not intended or offend fort talc (Sm. 7064. Business
and Professions Code: The Conuactoh License law does rot apply to an owner of
q P
property who builds or imposes thereon.and whodauauch work himselfo Waugh ha
awn employes, provIded that such Improvement, art not Intended or offered lorsale. If.
however, she building or improvement Is Sold Within ons, year orcompletion, the owner.
Wilder will Nie die burden of pmving Nat la did out build or Improve fa popose of
ASIA.).
D 1, as Owner of the Property am exclusively contracting with licemed Con owu s u
Conoat, the pmjem (Sec. 7044, Business sad Profession Cade:) The Com acuu'& Li.
cause Lav does mol apply in an owner of property Wha builds at improves Sharron. and,
who connects for such pmkcte with a convsslor(0 licensed pursuant to as Contractor's
License Law.
D l em exempt undo Sec ,B@PC fo this moon
Owner Data
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury am of as following dedmalau:
haw end .111 ..deal. a Certificate of Consent to ulRimas. I. Work elComPen-
n, u provided four by Section 3700 of the labor Cole, for W performance of W
k for which Ni& permit is issued.
love sad will meinWn Worker's Compensation I.., u mqul¢d by Section
1037.1"
0 of the labor Code, for W performance of W wok fo which Nis Permit is issued.
Worker's CmnpoSallon Inronnce nnier and Policy numbr sae:
rier. PoIbYNo.:f2cLMtpa15330'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thiseecdm need Out heconplcad Ifihe permit is fnsOne hunJseddollara (SIO)
or leas.)
I unify that In the performantt of use work for which this permit is bused, I shall not
employ enypnon In any manor an AS Se become subject o the Workers' Computation
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Ceniftcate of Exemption, you should
became subject a W WorkeM1 Compensation provisions of She labo CMA, you must
forthwith Comply With such provisions or this prmluhell be de m d revoked.
CONSTRUCTION LENDING AGENCY
I hereby Norm WI mirt la larding agency Torahs performance of
sued (m . 30
the duh for which this permit b band (Sm. 11197, Civ. CJ
Lender's c
'
lender's Add Addrtu
i 1 unify that 1 Mw read this application and sum that W &how Wronnallun b
' Correct. 1 agree m comply with all city and county ordinance, and Sam bws misting m
Wilding construction, and hereby uthodn mpresenmives of this city to enter upon the
I abovomemiOmd property for ms Ccdon purpose,
(We) agree to Save, Indemnify and keep hamlleSa the City of Cnpertho agatmt
i liabllitat,judgments, coast and expenses which may In any way accse against Said City
in his ntrit.
I APPLICANTOUNDERSTANDS or the Smoling of IAND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
4/:2/
��j'.� 05
Re -roofs
Type of Roof
Signelurc ofApplicaHAZARDcOUS MATERIALS DISCLOSURE Date
Signature
Will the applicant or future building=openulOra or handle huardous materiel
AS defined by the Cupertino Municipal Code, Chapter 9.12, and the Health sad Safety
Code, Section 25532007
Dyes u
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 am equipment or devices which
I hazardous air contaminant, u� donned by the Bay Arca Air Quality Management
all new materials for inspection.
IS Ifn
❑Yes Vr-
1 have mad the larAnI mmderiehreyulrtmenla under Chapmr6.93ofiheCelifor-
nice Hod" SefclyCodc, Seclloat 25515,25533 ud25534.I understand that If nm Sundial
Jac& not cunemly haw A tenant, that II Is my respooth lily to nonny W mcupul of the
rcquimmenu which must bC et Prior lis heuu ra6odnesm ar Ocmpmny
Signature of Applicant Date
All roof coverings to be Class "B" or better
OWnar of authori. agent Dote