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CITY OF CUPERTINO
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BUILDING DIVISION PRRMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITNO.
04090157
M
PERMrr ISSUE DATE
RTNERS
I
999 AT,,114A STREET
SANITARY 0 OLNO.
ARCHITEC IENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o t�
LICENSHD CONTRACTOR'S DECLARATION
Job Description
1 kmby afflrmIhal 1 am Iicco cd under provisions of Chapter 9 (commencing
with Section 700(1 of Divltlon 3 of the B"Mnes. end Professions Code, and my license Is
uanseCl::and `fr"` LI,.g 3
-NEW CONDO -1111 SQ. FT.
Dam Cafh.lar
1
ARCHITECrs DECLARATION
1 undcpl d my Pbm ahatl k�led.a(Puh e m
LIccnsoJ Pmfeainn11
OWNER -BUILDER DECLARATION
exempt from the Commoner License Law for Ik
I hereby that I from
Maso .Affirm
L mineu and Cade: Any ekty m county
following reason. (Semon 7(1313,
sae. dmiom
which re9ulrca a permit re construct. aka Impmve, de m repair any aWetum
Permit t
phial or its IYaOUM,aBU required theapplicantof for UMhamiscl elafileasignedaYNmeal
redth
Littme Law (Chgen9
Sq. Ft. Floor Area'
Valuation
Punuent talk of Divisionf thehe BushroYa
Ch.
(that commencing Division of eumd of
(commenting
for al egad on. Any madonCode)
Jut k LL hemp therefrom and die bath far aim 111ge0 exemption. Any vlolatiM of
pt Lhection rchrum1and the
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit anbjects the applicant m a civil penally of
not mom than Div hundred down (55004
0 Lumvmr ofthe property, mmyemplaycu with waguu thei"oleeomPenmaJan,
31620084.00 Required Inspections
will do the work and theswnurtisnot lmendedoraRcred Astaire (See. 7044. Business
end Profeu11 Code: The Commence, Llceme law does not apply o an owner of
q P
propeny who build.. improvesthereon,andwho does,mh work him ndforthrough him
own employees. provided Net such Improvements arc not Intended or offered formals. If.
however, the building or Improvement Is sold within au year of completion, the owner.
bulkier will have the burden of proving that he did not Wild n improve for purpose of
mete.).
0 I, as owner of the properly, am exclusively convecting with licensed contractors to
construct the project (Sec. 7044, Business and Professions Code:) The Canuacmrt Lb
came Law does not apply to an owner of property who Wilda or improves thnco", and,
who contracts for such projects with a contractor(s) licensed pursuant to the C01011CI is
Lcenw Law.
0 l em exemptunder Seo. ,B k PC for this recon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury me of the following declinations:
haw and will maintain a Certificate of Convent to mel( -ileum ran Winters Campem
anti"., u provided fer by Section 37M of the labor Code. for the Performance of Ja:
work for which this permit Is issued.
ofhave and will maintain Workeh Compensation Cusumano, u required by Section
3700 of Ne labor Code, fn the performance of the work for which this Permit is Issued.
'y' once. Compensation Monsoon carrier and Polity number art:
Carder: /443e.57;r Poliry No.: CNG? 9i
,
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Nis section need not becompleted if the Permit Is foram hundreddollm ($IM)
lir lees.)
I certify that In the performance of the work (a, which this Permit is lured, I shall nal
employ any person in any manoenn M to become subject to lbe Workers' Compensation
Law, of California. Date
Applicant
NOTICE TO APPLICANT: If. atter making this Cenificeto of Exemption, you should
become subject m the Worker's Compensation provisions of the lakr Code. you must
forthwith comply with such provisions lir this Permit hall W deemed invoked.
CONSTRUCTION LENDING AGENCY
I kmby affirm that dare is a construction lending agency for the performance of
the work fn which this permit Island (Set. W. Civ. C.)
lendds Nurse
landefs Address
'
I i certify that 1 have read this application and sum that the .bow Information Is
' cormct. I rgme to comply with all city and county ordinances and rete law relating w
W lldoI c...aucJon, and hereby authodrt represernuirea of this city to enter upon me
above-mentioned property for Inspection Purpose..
I (We) agree to caw. Indemnify and keep harmless the City of Cupertino .111"1
j liabilities.Judgmen0. costs and expenses which may in any wry acme against midCity
In APPLICANT granting
ANDof WILLANTUNDEWILL COMPLY WITH ALL NON -POINT
Issued by; Date
SOURCE REGULATIONS.
Re -roofs
Type Roof
'
Signalurc of AppilcantlCont; iffor Delo
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or factum building occupem state or handle harudo" matedal
as defined by the Cupertino Municipal Code, Chapter 9.13, and Me Health and Safety
ado, Seeline 35533(.)9
Nu
All roofs shall be inspected prior to any roofing material being installed.
D Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant of fumes building occupant use equipment or dcvkms which
harardou, all contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
6 ❑ Yw
I haw read aim hantdnum materials requirements under Chapter 6.95 of the Califon
:1"SalclyCade,Snvmu355(13,
Id-
33577 anJ3553/.lunderstsM thulfJw Wilding
net currently haw a o"nl. that it LL my respo"Ihiliry m notify the occupant lir the
ircmenu which MUM Wm�el p�rl—✓orm/iutencears cenifium oraeul�cy.
Signature of Applicant Date
`�y'2l
All roof coverings to be Class "B" or better
ner sir mlhodvx tem Dale