040901566
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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UNTRACTQR INS'® MATIQNs
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090156
AM
PERMIT ISSUE DATE
E:
SANITARY OL NO,
ARCHITECT/ENGINEER;
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby Mrm than I am licensed under provisions of Chapter 9 (commencing
with Section 70(117) of Divldon 3 of the B.d.A and Pmfcuinns Code, end my license le
In mummeatdeffect. n
License Cl Lic.6 B�Ds/'I
NEW CONDO -1111 SQ. FT.
-
Dam comments 50fo'
ARCHITECPS DECLARATION
I onMm rad my phot ahaiI be used ublic recn
Licensed Pmfe..rural
OWNER- )ILDER DECLARATION
1 hereby affirm that I am oaomPt from the Contractor's License Lew for the
following meson. (Satiun 703 L5, Business and Prtdeulnns Code: Any city or county
which requires a Permit to ennnlucl, alter, improve. demolish, or repair any analere
prior in it, lung=, Alan mr moss the applicant for such permit to file asigned statement
Net he is licensed pursuant to lM provisions of tiro Contractors Licents Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 1000) M Division 3 of the Business and Proteainns Code) or
Nu he is exempt themfram and the basis for Ihn Alleged eumption. Any violN6n of
APN Number
Occupancy Type
Section 7031.5 by arty Applicant for A Permit objects the APPlicanuu A Civil FMAlq of
And more than five hundred dollars ($5007.
0 1, an owner of the properly, m my employees with wages As their sole compensation,
31620084.00 Required Inspections
eenueclo',
wllldo the work, and theammium is not intended oreffeled fomal.(SAc. 7044, BGirou
and Proul License Law dors not apply an owner of
feom Code: The Cm
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property who buildsorimprov immune. and who does such work himalfor through his
own employees, provided Na such Improvement, am our Intended nroRered for We If,
however, the building or Improvement is sold within one, leu of cemplefion, the owner.
Wilder will have Ina burden of proving that he did not build or Improve for purpose of
um J.
0 1, a owner of tins property. am exclusively contracting with licensed convenors to
eosin et the prolan (Sr,. 7044, Business and Professions Cade:) The Contractor's U.
cents law dues not Apply to an owner of property who builds or Improves thereon, and
'
who contracts for such Wolcott with a contnnor(s) licensed pursuant ne the Consomme,
License law.
0 lame.emmunder Sec .B&PCforlhhfeuon
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby anirm under penalty of pdury one of the following declarations:
have and will maintain a C.rtlfiL.le of Cement to tsl0lnsum for Workmen Cempn.
niton, a provided for by Section 3700 of the labor Code, for the performance of the
smrk for which this Permit Is issued.
0 1 ham and will maintain Workcrs Compensation Insurance, u mqumed by Section
.
31110 of the labor Code, for 0t, performance of the soak for which this Permit it Issued.
My Workers Compnntinn Inannae Grtier and Polity number are:
Canter. M4s - C Tw'.Policy No.:4di Cf170%.�$J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed If the Permit is f crone hundred dollars (SIM)
or less.)
1 centry Net In Ne prf ..am of the .,it for which thin Permit is Issued. I atoll not
employ Anypann In any macer N G b become Nbjmt to the Wodaus' cempensallem
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, afar making this Certificate of Exemption, you should
octane object m the Work.'. Compensation provisions of the Labs Code, you mus,
forthwith comply with such provi lom or this Permit shall M deemed revoked.
ON LENDING AGENCY
CONSTRUCTION
inemhyichvm than Them is a construction agency for tins performance of
0lending
issued
' the work for which this prm0 h loved (Sec. 3097, Civ. Cd
1 lenders Nam.
Iendeh Address
j I certify that l have mad this applimion and cum that Me Atom Infonnalon In
comm. I agree to comply with all city and county ordinances and Marc laws relating to
Wilding contraction, and hereby authorise mpresanutives of this city to enter upn the
above-mentioned property for Inspection purposes.
(We) agree to um, Indemnify and keep harmless the City of Cupertino against
j liabilities.judgments, costs And expenses which may in any way accme against old City
In consequence of the Stenting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCEREGULATION
// 'Y' I'" i
Re -roofs
Type of Roof
SiSrummofAppicasilComosucher Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or future building occupant atom Al handle harudous material
in donned by the Cupertino Municipal Code, Chapter 9. 12, and the Health and SAlmy
Code, Sectio 15531p)7
All roofs shall be inspected prior to any roofing material being installed.
❑ YG
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Wdi the applicant or future building oceupm use cqulpmem or devices which
I hardens Mt contaminants u defined by Ne Bay Am Ail Quality Management
all new materials for inspection.
7 %
❑YC{
1 hem reAd the heaNrws materials requirements under Chapter 6.95 of t t, Califor.
ole Health & SaR yCede, Suctions 15505,15533 and 15534.1 undcumed Mallftho building
dues not curscndy hem A m ... I. Nu It is my mapnslblllty, m notify NC eccupant of the
requirements which must be met prior¢iuuoaofa Cerdnelmof OccuPucy.
Signature of Applicant Date
12
All roof coverings to be Class "B" or better
owns a anthntiyed em DAte