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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
CON` Nal IN MA YOly ,
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090160
OW ER's A E:
PERMIT ISSUE DATE
SANITARY N L NO.
ARCHITECTAINGINEER:
BUILDING PERMIT INFO
BLDG ELP.Cr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Ib Description
r 9 (commencing
that I am Emitted under provisions Of Chapter
I beauty affirm li
with Section 7W0) ol'Divlsion 3 of the Business and Profaonn CMe, and my license is
in full forte end effect.
License Clea Lic.p �%gDy_%
S
NEW CONDO -1111 SQ. FT.
-
Date Contractor PA L10r JSA,07
ARCHITECTS DECLARATION
I understand aphM- MJI W used u pts Tic recmrl —
Licensed Professional)
OWNER -BUILDER DECLARATION
1 berchy affirm that I am exempt from the COmnmar, License Law for the
following mann. (Section 7(01.5, Business and Profession Code: Any city or county
which requires a Permit to constmct, alter. improve, demolish. or repair any structure
poor to its issuance. also rcquiranhe applicant for such permit to rile a signed storemem
Sq. Ft. Floor Area
Valuation
that he is licensed pennant to the provisions of the Contractor', Umnse Law(Chapmr 9
(commencing with Section 7") of Division 3 of the Business and Fmfessin r, Code) or
Nal he Is exempt therefram and the boos for me alleged comptom Any vlohdon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penally of
not moa Most five hosted dollen ($500k
❑ I. u owner ofthe property, or my employee with wages u Men sole compensation,
31620084.00 Required ins eetions
er
will do the work and the Name, is ontinmnded Mothered Antole(See. 70/1, Boom,
and Profession Code: The Commute. License Law dna nal apply In an cancer of
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property who builds or i m prows thereon. and who does,uh work Manse If or through his
own employcu, provided than such Improvements tie not intended "Offered In am. If.
however, the building n Improvement is sold within ane yen of eompledon, the Owner.
builderwill have the burden of proving door he did not build or improve for purpose of
.mJ.
❑ 1, as Owner of the property, am exclusively contracting with Iicamed mnlncmn to
commOct the probes (Sec. 70th, Business and Prafusiou Code:) Tlm Committees U.
cense Law does not apply to an owner of property who builds or Improws thereon, and,
who contracts for enah Projects with a mmo cter(Q Ilmosed pursuant o doe ConlnctoM1
License Law.
❑ I am exempt under Sec. . B A P C far this rcuon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following duhrator.
'
1 have and will mainuln a Cenifesu, of cannot to Mir -Mons for WorkeraCompen-
tion, u provided for by Section 7700 of me labor Code, for Ne performance of the
work for which dols permit is laved.
❑ 1 have and will ..Intel. Workers Compensation Tonna, u rtyubed by Sudan
fn which cels permit la d.
3700 of the labor Code. for Ne performance of Mm worst lau
My Worker's Compensation Intunue carrier and Policy number arc:
Carrier. HAJ<yRmG Tt! PoIIryNo.:�S33ns'
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Till acdenneed not Mcmnpated if the permit Is (none hundred dollen (SIM)
or lust
I certify that in the performance of the work fn which this permit is brood, I Nall not
employ any Ferman In any manners u to become object to the Worker' Compensation
Law, of California. Delo
Applicant
NOTICE TO APPLICANT: If, after making this Cenifina of Exemption, you should
become subject to the Worker, Compensation p robion of the labor Code. you must
fanhwith comply with such Provision or Nis permit hall he deemed revoked.
CONSIRUCnONLENDING AOENCY
I hereby a0irm that mart b a lending agency for Mm performance of
rd (Sm. 0
Me wars for which this permit is iismd (Sm. 7097, Clv, C.)
Lando. Name
'
'
lenderi Addw
I unify that I have read this application and met that the .bon Informal. i,
correct. I agree m comply with s11 city and county ordinances and sate law, relating to
building mnstuction, and hamby amhodm represemstive, of cels city to enter upon the
above-memioned propcny for Inspection purlwso.
(We) agree to ave, indemnify and keep harmless, the City of Cupertino against
liabilities. judgements, costs and expense. which may In any way seem against'Old City
in I his rmit.
ANTUNDERSTANDS WILL COMPLY WITH ALL NON -POINT
APPLICeRNof the joeuing of IAND
Issued by: Date
SOURCD REGULATIONS.
Re -roofs
Type of Roof .
Signamreof AppHea oarmul. Dale
HAZARDOUS MATERIALS DISCLOSURE
Will 0m applicant Or future Wilding Occupant store or handle haardoat mammal
u defined by the CupertlnO MunINMi Code, Chapter 9.17, and the Health and Safety
de, Section 75577(.)7 }��
0Yes
All roofs shall be inspected prior to any roofing material being installed.
i1
If 8 roof IS Installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment n dcvMa which
Itheurdnu,air anDualrants a defined by the Boy Ana Air Quality Management
all new materials for inspection.
ale@ .�
❑ Yes
Ida
I have mal the Wroolm,materials requirements under Chapter 6.95 orthe Califno
.isHDeINk Safety Cade,Sm:don75505,75577 and 75511.1 undentsnd lhaNfmc building
not currently haw a knot. that It is my responsibility to nod ly Iha occupant of Ne
uirements which must W met prior to issuance of a ceNficate of Occupancy.
Signature Of Applicant Date
°
All roof coverings to be Class "B" or better
ner or methoozem Dam