04090149CITY OF CUPERTINO
BUILDING DIVISION PERMIT
BUILDINGADOREss:
PALISADE BUILDERS INC
PERMIT NO.
O E ME:
PERMITLSSUEDATE
NE:
SANITARY N11"' OL NO..
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDGO ELECTO PLUMS MECHO
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby (firm that I am licensed under provision. of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code,and my license is
in full force and .(feet. S
Lmenm Clas LM.g
•NEW CONDO -1087 SQ. FT.
Date n CubsCom 01,014imftoz
ARCHITECTS DECLARATION
I untie nJ my plena ehellbcym pub' m�nrM
Licensed Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from be Contractor's License Law for the
following reason. (Section 7131.5, Business and Profesaiong Code: Any City or county
Which requires A Permit on consumer, altar. Improve, demolish, or repair any almclum
prior to its issuance, also require, the applicant for such Permit m file a signed Statement
Sq. Ft. Floor Area
Valuation
that W lS licensed pursuant les the pwhilena of Ne Contractor's License Low (Chapter 9
(commencing With Section 7000) of Division 3 of the Business and Profession, Code) or
Nat he is exempt Momfrom and me basis fm the alleged exemption. Any violad,on of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than five hundred dollars ($500).
❑ 1, AS owner of the property, or my employees with wages As their Ole compensation,
31620084.00 Required Inspections
e
will do the work. and the Mumure is not intended or offered for W. (Sec. 7044, Business
and Perfesslons Code: The Contractor's License Law does not apply O an owner of
q P
property who builds or Improves thenen, and who dmt,uch work himself or through his
own employees, provided that such improvements arc not intended oro@red formic. if.
however• the building or improvement Is sold within one year of completion, the owner.
Wilder will have the burden of proving that he did not build or improve for purpose of
sale).
1, as Owner of the property. am exclusively contracting with licensed contractors to
construct the project. (Su. 7044, Business and Professions Cade:) The Contractor's U-
Conse Law does not apply in an owner of property who builds or improves thereon. and,
who contmms for awls projects with a eonuacmr(Q licensed pursuant M the Contractor',
License Law.
❑ 1 am exempt under Su. . B k P C ror thisreason
Owner Dom
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury ane of the following deeluatimm
1 have and will maintain a Certificate or Consent to self -insure for WorkeesCompen-
don, a provided for by Section 3700 of be Ube, Code, for the performance Of the
work for which Nis permit is issued.
❑ 1 have and will malnuin Worker's Compensation Insurance, a required by Section
370( of Ne Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier, W43-5l;c .%GC. Polley No.: 6.3D�LR �u11-��L
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This motion need not he Completed If the permit is for.nc hundred dollen ($100)
or lest)
I certify that in the performance of the work for which this permit Is issued, l shall not
employ any person in any manncrso As to became subject o the Workers' Compensation
,
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If, &der making this CenIfICAIC of Exemption, you should
become anhjat to the Worker's Compensation provisions of the Labor Code, you must
forthwith Comply with such provision or this permit shall be deemed revoku 1.
CONSTRUCTION LENDING AGENCY
1 h meby'.M. that them is ....traction lending gency forte Performamr of
M. work for which this permit is Issued (Sas. 3097, Civ, C.)
Lender's Name
Lender's Add..
I canify that 1 have read this application and Item that the above Information Is
come[. I agree to comply with ail city and county Minnows and sum laws relating to
building construction, and hemby authorise repmsenlalives of this city to enrer upon the
abovomentioned property for inspection purposes.
(Was) Agree Its save, indemnify and keep harmless the City of Cupcnmo Against
Ilabilida.judgmcnW costs and expenses which may In any way acme against Said City
in his rmit.
ANTUNDERSTANDS WILL COMPLY WITH ALL NON -POINT
APPLICeRNof the granting of tAND
Issued by: Date
SOURCE REGULATIONS
Re -roofs
Type of Roof
�/�'�Y--'
Signature of Applic .nlnctor DAM
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant emus Or handle hazardous material
a deNMd by the Cupertino Municipal Code, Chapter 9.12• and the Health and Safety
Cade, Section 35533(x)7 /
All roofs shall be inspected prior to any roofing material being installed.
"'a
❑Yee �u
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant m future building Occupant use equipment m devices which
i hazardous air contaminants u the by the Bay Arca Air Quality Management
all new materials for inspection.
Islrictq /
❑Yes /�691R
-A
I have mW thehaaamnusmamrial, mquiromenu under ChOwr6,95 ofthe Califon
ole Health A, SAI.wCede, Sections 25505.25533 and 25534.1 understand Ihetlfthe (wilding
does not currently haw: a tenant, that It u my nespoalhithy to modify the occupant or the
myubouncrts which most be met prior to issuance ora CcnlficaM of Occupancy.
Signature Of Applicant Date
' ��� e/•� p
All roof coverings to be Class "B" or better
Owner m.uthormed ag� Date