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CITY OF CUPER't'INOe'�
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT Nb4090154
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PERMITI%E DATE
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SANITARY NO. CONTROL NO,
ARCHITEC IENOINEER:
BUILDING PERMIT INFO
BIRO ELECT PLUMB MICH
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LICENSED CONTRACTOR'S DECLARATION
lois Description
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1 hereby affirm that I am trained under provision, of Clupter 9 (commencing
with Sudan 7") of Division 3 of du Busineat and Professiotn Cade. and my license is
in full forte md.ffecl.
License Clan LIc.g
l°A`5
NEW CONDO -1111 SQ. FT.
Dem ° Coaw, /ISA/C
AR HITECrS DECLARATION
I undemanJ my plans oedJ• f••w�l{I�_
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LlcenseJ Pmfeasmwl v
OWNER -BUILDER DECLARATION
I hereby afOrm that I am exempt from the Comsamars License taw for the
following rtoann. (Secure 703 1.3, Business and Professions Cole: Any city or county
which requlro, a Permit to commuct. alter. Improve, demallsh, or repair any structure
PHOT m its issuance, also requires the applicant for ouch permit m Ole aligned statement
that he is licensed pursuant in the prwhinnn of the Comment's License law(Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7") of Division 3 of IM Business and Professions Code) or
$128609
Nm he 1s exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Perth subjects the applicant to a civil penalty of
not moa than Ove hundred dollen (5300).
_
❑ 1, as owner of the property, or my employees with wages at; their sale compensation,
31620084.00 Required Inspections
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will do am wort, and the gtrctum is not intended or offered for sale (Sm. 7044, Business
and Professions Code: The Committee License law data not apply to an owner of
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property who builds ter improws thereon, and who does ouch work himulf orthrough his
own employees, previous! that uch Improvements are not Intended proffered forage. IL
however, the building or improvement is veld whom one year of completion. the owner
builder w10 haw the modest of proving that be did ant Wild or improv for purpose of
ole.).
❑ 1, as Owner of the property, am exclusively contracting with licensed contractor, 0
contrast the project (Sec. 7014, Bualnw and Professions Code:) The Contractors LL
scree law does nm apply to in Owner of property who Wilds or Improves thereon. and
who contracts for such prekna with a conusetor(s) licensed punuanl to the C.Olona rs
License Law.
❑ lameaemptundem Sea ,B@PCfurthumason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I he a irm under penalty of Perjury ane of tan following awasatioas:
Mw and will malnuln a Certificate of Conxens1. If ingre for Workrr.Compw-
sa0on. u provided for by Section 37M of ase labor Code, for the performance of the
work for which this permit I, Issued.
❑ 1 haw and will maintain Workers Compensation Nronnce. as required by Section
37M of the labor Code, for the pertormawc of Ne work for which this permit Is lured.
My Worker. Comparmulm. Insurance carie, and Policy names, son:
Carrier: M �'�orgb2S3r3o,�
qMfION
FROM WORKERS'
'
COMPENSATION INSURANCE
Gbb section need not becompleled IHhe permit Is furore hundreddollan (SIM)
or leas.)
I certify that In the performance of the work for which (his Permit Is Issued. I atoll not
employ any Person in any manner an u to become subject to the Worker" Compensation
Laws of California, Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
became subject to the Worker's Compensation provisions of the tabor Code, you must
' forthwith comply with such provisions or this permit hill be deemed revoked.
I
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them Is, construction lending Jwmy (of be Performance of
' the work for which this permit Is laud (Sec. 3097. Civ. C.)
1 fender's Name
Lands,'.Addreas
i 1 unify that I haw read this application and sum that the abew Information is
' corecL I agree to comply with all city and county ordinances nd sou laws relating to
Wilding construction, and hereby gunnels, representatives of this city to cater upon us
i almw.mendwedproperty for inspection purposes
(We) agora to saw, indemnify and keep hearings the City of Cupertino against
j liabilities, judgments, cauano expenses which may In any'w'ay am= against said City
7 APPLICANT UNDERSTANDS Aof IND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS,
Re -roofs
Type of Roof .
Signature of ApplinnVp nlrCan Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant store or handle havudous material
as defused by the Cupeniro Momelpal Cade. Chapter 9. 12. and the Health and Safely
Code, Section 25532(,)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or furor Wilding occupant use equipment or devices which
I hnsrdous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
Joliet?
❑ Yes
I have roaJ the hummuus materials requirements undcrChapur 6.95 of the Califor.
nia Health A SafelyCodo, Sections 25505,25533 and 25534, 1 undcmmund that if the Wilding
does not currently haw a enact. that It u my responsibility he nodl'y the occupant of the
requirements which mug be me( prarmtsanana a(a ctAne.0 or Occupancy.
Signature of Applicant Date
Q/ °
All roof coverings to be Class "B" or better
Owner or authadyed apAl Dam