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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDINGADDRBS:
PALISADE BUILDERS INC
PERMIT NO. 04090155
OWNER'S NAME:
PERMIT ISSUE DATE
E;
SANITARY N OL NO.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 70M) or Dlvlalon 3 of the Degree, and my license Is
�andpPprof�ustio�ns `Code,
in full force and effect. DJO'-'4 s�
`MAL a ate.«
NEW CONDO -1111 SQ. FT.
Doss H • IML. 0,5 Connector C AU.:
ARCHITECTS DECLARATION
I unde tsnJ my phnuhsil he used u ublic cnrN
Licensed Profcsloml
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Comnclol" Lli law for IM
following Maven. (SCNut 71313, Business and Professions Cale: Any city or county
which requires a permit to temmnCl, alter. hop ow, demo)Ah. ter repair any structure
prior m its isuanm. also requires the applicant for such permit to rile ,signed statement
Sq. Ft. Floor Area
Valuation
that M is llccmed punoamm the provisions of the Common' Lhcnm Law (Chapter 9
(commencing with section 7000) or Division 3 of the Businessland Professions Code) or
that he Is exempt Nerefmm and the basis for the allayed cumpdon. Any aimed an of
APN Number
Occupancy Type
Section 7031.5 by eery appllCant for a Permit subjects the applicant to a civil penalty of
not more than rim hundmd dollen ($500).
❑ I, As owner of the propeny, or my employees with wages As their auto eempenalion,
31620084.00 Required Inspections
will do the work, and theanuctuM is not ntended proffered Austin(See. 7041, Business
and Professions Code: The Coninclor'1 License Law does not apply m an Owner of
9 P
property who builds or improws Nemon, end who does such work himself m through his
own employees, provided Nn such IMProwments t,e nm Intended oroaemd foreale. If,
however, Ne building or improvement it mid within one yet, of completion, Ne owner.
builder will haw the burden of proving that he did set build or Improve for pulp. or
Ne.).
❑ 1, as owner of the property, me exclusively wrinowdng with licensed cpmndon to
Construct the project (Sec. 70:1. Business and Professions COMA) The L`anVxCIW'{ u -
Leve law dos not apply to an owner of propeny who builds or Improve$ Nemon, and
who contracts for such projects with a Aonbsctofs) licensed punvnno the COMOCIGel
License Law.
❑ I am exempt under See. ,B@P C for this Mason
ower Date
WORKER'S COMPENSATION DECLARATION
I hereby $Bim under Nulty of perjury aOc of the fallowing declamlons:
ham and will maintain a CeniBnte of Covent m ulFloaum for Worlones Compen.
minn, u provided for by Section 3700 of the Labor Code, for Ne performance of [be
work for which this permit is Issued.
❑ 1 haw and will maintain Worker's Compensation Marmara, s required by Section
31M of the Labor COCA, for Ne performance of the work for which this permit is issued.
My Worker, Compensation Insurance envier and Policy number are:
Co.ter. /7AJGS%:C .f fnsC Polley No.:GtOpR32e%�.�0
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Our Motion wed not becomplered )f the N mit is lmaneh esdoul dollars (SIM)
or IesJ
1 eeniry, Net in Ne performance of the work for which this permit is lead. I shall not
employ any person l0 any mannerm O m wournm mbj CL to Ne WayTTf Compensation
Laws of California. Dam
Applicant
Nance TO APPLICANT: If. after making this Cenifinte of Exemption. you should
become subject to the WoheM1 Compensation provisions a the labor Code, you must
forthwith amply with such provisions or this permit Aml be dcemed remote,
CONSTRUCTION LENDING AGENCY
1 hmeby $Rum Nn them Is construction tending agency for the performance or
the work for which this permit is Issued (Sue. 3097. Civ. C)
Lender's Nlme
Lender's Address
1 cenify that I haw read this application and mass that the above Information It
comet. I ngMC 10 Comply with all city and county ordinances and sure Iwo palating to
building construction, and hereby authorize MPOMCMmws of MIS city to Anter upon the
above•menlioned pMperly for lnepenlon purposes
M
(WA) agpae to taw, indcmniry and kap Immodest the City of Cupertino tgaivt
j Ihblline( judgments, costs and expenses which may in any way seem against aid City
In s rmit.
APPLICANTUNDERSTANDSAor the soming or I
ANTUNDESTADS WILL COMPLY WITH ALL NON.POINT
ND
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of Roof
% /r-� `f-21 '°S
SignuM of AppllesnVCo rano Dass
m
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building oaupant mom orlundie husdous massdm
as defined by the Cupertino Municipal Code. Chapter 9.1x, and the Health and Safely
cude."Amianxss3x(.)7
NO
All roofs shall be inspected prior to any roofing material being installed.
QYus
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicmt or future building Occupant tau equipment or devices which
havardens air contaminants As dented by the Bay Area Air Quality Management
all new materials for inspection.
strut?
❑ Yes
1 have mad the hasrJnmm$Nrlals nquinemenu under Chapter 6.95 of the Collier.
Me Health d safetyCode. Societe 25505,25533 and x5534.1 undougu d that If the Wilding
time not currently have a scum, that It is my responsibility to will'y the occupant of Ne
requirements which mum M On prior m issuance are cerdficato of Occupancy.
Signature Of Applicant Date
a Dir
All roof coverings to be Class "B" or better
Owner tar mthvi'rcd a t Date