04090151CITY OF CUPERTINO
BUILDING DIVISIONPERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090151
A
PERMIT ISSUE DATE
SANITARY ROL NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby ofrtm that 1 am licensed under provision, of Chapter 9 (commencing
with Section 7000) of Division 3 or the Businea and Professions Code, and my license is
in full force Intl cIf /038 �/� 6
License Cie. Llc.p G
NEW CONDO -1087 SQ FT
Dam Contractor :34da— ff./,lepks
ARCHITECTS DECLARATION
'
I undernmJ my plem shall he reed a public
License) Pmfessinnal—
OWNER BUILDER DECLARATION
I heathy .(Sere that 11. exempt from No Canlrsclofa License Law for the
Coda: Any city as county
following recon. (gallon 7(131.4 my
After. and
deo
,
improve. demolish, or repair any r
which requires a permit re enreweL eller, Impmw,
r.
statement prior m its laved, also requires the applicant fonuch pctmil m 01st .maned atammbnt
hPermitt
Sq. Ft. Floor Area
V81aa[lOn
that pursuant to Um theeBusinss LictnseLaw
ofDivionsof
the lation or
with Section 7000) of Division 3 asho(ChapterCode)
rnmeringwit and Proficon.
(cat
use alleged exe Any vi
Nal he Is exempt therefrom and 0e buil for the alleged exemption. Any violation of
he Is xe
-
APN Number
Occupancy pe
Section 7031.5 by Any applicant for a permiuubjec s the applicant ro a civil penally of
not mom than Eve hundred della. ($500).
0 1, u Owner of the property, or my employees with wage, As their sole compensation,
31620084.00 Required Inspections
will do due work, and theamctum I, not intended ora0ercd ersaie(Sec. 7044, Business
and Professions Code: The Contrulorl License Law data ret apply he an owner of
property who builds or improves thereon. and who doer such work himself or through his
own employee,, provided that such improvements arc not intendW oroRered fors,le. IL
however, the building or Improvement is mid within one you of compledon. the owner.
builder will have the burden of proving that he did not build or Improve for purpose of
ala).
O I, as owner or she property, em exclusively contracting with licensed contractors 10
construct the pmject (See, 7014, Business and Professions Cada:) The Contractor's U.
cense law does not apply in an owner of property who build, or improve thereon, and .
who contracts for such proJCCM with A canlraler(I) licensed puuuam to Can Cont.et0el
License Law.
❑ 1 am exempt Cotler See . B At P C for this rcmen
Owner Dae
WORKER'S COMPENSATION DECLARATION
I hereby Affirm under penalty of perjury one of the following declarations.
have and will maintain s Cenlficate of Consent to,el6lnsum for Worker's Compnn-
tion, an provided for by Section 37011 of the labor Code, fu the performance of the
i, permit is ed.
work for which Nmus
r_1 1 have and will maintain Worker's Compensation Insurance, a required by Section
3700 of the labor Cada, fa the performance or the work for which this permit I, ivatd.
My Workee, Compensation Inanae carrier and Policy number em:
Cartier•. AAI&57;e Tsw C Policy No.: L1' Cs[YV12xSi'
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the permit is for one hundred dollars (5100)
nr Icss )
1 certify that In the perfmmmca of the work for which this permit is Was. I shall not
employ any person In any manner an As, an become subjauo the Workers' Compensation
Laws of California. Doc
Applicant
NOTICE TO APPLICANT: If, aftor making this Certificate or Exemption, you should
baome subject Co the Worker's Compensation provisions of the Labor Code, you must
' forthwith comply with such provisions or this permit hall he deemed revoked.
ON LENDING AGENCY
CONSTRUCTION
is a construction lending agency for the Performance of
hereby Nat (here LLsee
which (Sec.30
' theLe work (ser which this permit b issued (Sec. 31197. Civ, C.)
Lender's Name
Leaders Address
'
I cenify Nu 1 have read this application And rete that the above latmo men Is
correct. 1 agree to comply with All city and county ordinance, and stere laws relating be
building cmatructien, and hereby summire representatives of this city tocntcr upon the
I above-mentloned property for Inspection purPosea
(We) agree to now. Indemnify and keep hamka the City of Cupertino Against
i IlabilificAjudgmane.co,B and expanse$which may In my way same against said City
In 2
APPLICANT granting
ANT UNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
417_ -2L -_6S-
Re -roofs
.7p a of Roof
SI{nature of Applin onh¢mr Dole�7y,
HAZARDOUS MATE RIALS DISCLOSURE
Will the applicant or Futuro building occupant oma or handle haadousd l
Safety
u darned by the Cupertino Municipal Code, Chapter 9, 12, and IM Health and Sddy
Coda, Section 255320)1
No
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 nr CultureIldin{ atcupem arae equipment or devices which
huardrus air contaminants As darned by the Bay Arca Air Quality Management
all new materials for inspection.
I61r1c17Elym
<
I have mad the ha.koes materials myuimmtnb underCTapnr 6.95 of the Califon
ole Health &Safety Cede, SCctons 255)5.25533 and 25534.1 undemmnd Nn if the building
does not currently haw a senan4 that It it my responsibility m notly the occupant of the
rcyulrcmanLL which manxm dopa issuance of a Carse&em of Occupancy.
Signature Of Applicant Date
/.O
All roof coverings to be Class "B" or better
Ownarunuthodm gtnl Doc