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Y OF CUPERTINO
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UILDING DIVISION PERMIT
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NG ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090150
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;ARCHITEL71SNOINEER:
PERMTr ISSUEDATE
SANITARY tfAOL N0,
BUILDING PERMIT INFO
BLDG ELECT PLUMB MBCH
LICENSED CONTRACTOR'S DECLARATION
lath Description
I hereby affirm that l un licensed under provisions of Chapter 9 (commencing
p
with Section 7")of Dl ,km 3ofthe Busfircoand Professions GWe.and my license is
I. full force and affect.
Lkenrecl..�L.• 1w{380�i
NEW CONDO -1087 SQ. FT.
Date H--11-ata. contractor rwit • ssk
ARCHITECTS DECLARATION
I un nand my plans shall M u ed a uM1lic
Licensed Profnssronel
OWNER -BUILDER DECLARATION
1 hereby affirm that I am exempt from the Commutates License Law for the
following moon. (Section 7031.5, Business and Prefeuiom Code: Any city Orcoumy
which inquires a Permit to ennsmmt, alter, improve, demolish, or repair any structure
prior to its issuance, also requires he applicant for such Permit to file a signed Statement
Sq. Ft. Floor Area
Valuation
that he is licensed puluanuo the Provisions of the Cnnloster's Lecture LAW (Chapter 9
(commencing with Section 7") of Division 3 of the Business and Professions Core) or
Nat Ite is exempt therefrom and the bash for the alleged exemption. Any violation of
APN Number
Occupancy VP
Section 7031.5 by .try applicant for a permit subjects the applicant to a civil Penalty of
not more than five hundred dollen ($500).
❑ Laaownsr whhvnguu th.(See.emm.
the property,ur myempuum
3162 0 0 84 0 0 Required Inspections
B.drun,
work. and ft is udes
for o l:P� t i
And dPreffeeCamrseme,
ns Cc&: The License 4w O an Owner
.
Company who builds m improve. thereon. and who do. such wort himself or through his
Own employees, provided that such improvements Are not Intended or offered forule. If.
however, the building or Improvement It old within one year of completion• Lha owner.
builder will have the burden of proving Nu W did not build or improve for purpose of
..R.).
❑ I• as owner of Om property, w exclusively contracting with licensed conmmrors in
consumer the project (Sec. 7044. Business and Prokulom Code:) The Cormooh Li.
camelaw docs not apply to an owner of property who build, or improves Hereon, and
who contracts for such pmjetu with a comaumr(s) licensed pursuant o the Comomm's
License Law.
❑ I am exempt under See. ,B@P C for this mama
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affhm under penalty of perjury can of the following dedantimm:
have and will maintain a Cenificate of ConsenNo self -Imam for Worker,COmPm-
tion. As provided for by Section 3700 of the Labor Code. for the performanof the
work for which Hit permit Is issued.
0have and will maintain Worker's Compensation Insurance, u required by Seedom
of Ne Labor Code, for the Performance of the work for which His permit I. issued.
My Worker. CompensNon Imm.no canis end Policy number am:
Cartier. Policy N..:53�
11MiOTEMPnON FROM WORKERS'
'
COMPENSATION INSURANCE
(MIs action need Am be completed IDk permh hrorone handled Mtlm($)M)
car last.)
1 cattily that in the performance of the work for which this poral, It luod, I shall not
employ any person in any mancer an as to become object to the Wormry Compentulon
Laws of California. Data
Applicant
NOTICE TO APPLICANT` If. After making this Certificate of Exemption, you should
become, subject in the Worker's COmpcmu,ian provisions of He Labor Code• you most
foMwith comply with such provisions At this permit shall be domed revoked.
CONSTRUCTION LENDING AGENCY
1 herby.Tette Her there I.. eon kndin{ agency fm the performance of
is=.is permit i. iu(Sec. 3O97, Civ. Cd
the work for which NCaused
Lenders Name
Lenderh Address
1 1 ttnlfy Hu I Mw read this application and tau that the .bow Information Is
correct. 1 Mose w comply with all city and county collocttund sue, laws renting in
Wilding coswetion• and hereby authorise representatives of this city res came upon He
ahove-mentioned PMPeny for IUPecdon Connotes.
(We) agree to taw, indemnify W keep b rnieu He City of Canard. against
i liabilities. judgments, costs and expensed which may In any way acerae against mid City
incoexpumofibegratfingofthI LIICCANT UNDERSTANDS AI
APPLND WILL COMPLY WITH ALL NON -POINT
Issued by; Date -
SOURCE REGULATIONS.
Re -roofs
Type of Roof
SijinnarmofApplickeddComuthem, Date
HAZARDOUS MATERIALS DISCLOSURE
Will He applicant or Count building Occupant port or handle Amadou material
o defined by the Cupertino Municipal Code. Chapter 9.17, and doe Health and Safety
Code Section 35533(.)7
All roofs shall be inspected prior to any roofing material being installed.
Ym
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fawn building Occupant use equipment Or devices which
It havadomair contaminator As defined by me Bay Am Air OUARly Management
all new materials for inspection.
'mitt] �u
❑Yet `� \
1 have read the huadmn materials requirements under Chapter 6,95 of the CAI i rm-
.in Heat" SstctyCodc.Salim'35505. M533 And 35534.1 undersand rest lflle, building
J. nm, currently have A tenant. it,,, It h At, responsibility on ratify the occupant of de,
requimmen'which mus, mmm poor to issuance or a ccoiReaa of occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or ant circ gent Dater