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CITY OF CUPERTINO
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OCONSTRUCTION
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BUILDING DIVISION PERMIT
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BUILDINO ADDRESS:
PALISADE BUILDERS INC
PERMIT N
004090161
ARIZATEVENS
PERMITISSURDATE
SANITARY O. CONTROL N0,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACT'OR'S DECLARATION
lob Description
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I hereby &form that l am Barucd under provisiono of Chapter 9 (commencing
with Section 7010) of Division 3 of the Businesaand Professlmn Code.and my license is
m"'tone and often.
License Clm Lk.1 3 -
NEW CONDO -1111 SQ. FT.
Ds¢ color. her c
ARCHITECI'S DECLARATION
Iund nun yplansshall u upuM/icjjl
Licensed ndesaianal s
OWNER -BUILDER DECLARATION
I hereby affirm that I em exempt from the Cantractors License Law for the
follnwing reason. (Section 7031.5, Business and Professions Cade: Any city or county
which requires a permit m cmmmct, alms improve, demolish, sir repair any structure
prior m its issuance, also Acquires the applicant for well permit m File asigned suumcnl
Sq. Ft. Floor Area
Valuation
Nal he is licensed pursuant m the prevision of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is exempt therefrom and the basis for the alleged exemption, Any violation of
28609
APN Number
Occupancy Type
Section 7031.5 by airy appllcant fora permit subjects the &,he., I... vil Penalty of
not more Nan five hundred dollars (SND).
❑ I. u ownat of the pmPeny,a myampluyaes with wAsea As libel, sole ampensatlon.
31620084.00 Required Inspections
WEI do dR warkand dlemandwe is not Intended m offered for sale (Sec. 7W/. Business
and ProfeWons Code: The Causucrora License Law dose ret apply ro an owner of
9 P
property who build, or Improve, there m.and whodo such sunk hmselfar through his
ownemploym. provided NY such improvements art not intended oroaered for ale. If,
however, the building or Improvement Is sold within one year of completion, the owner.
builder will have the burden of Proving Out he did not build or Improve for purpose of
aleJ.
❑ 1, as owner of the pmpeny, am exclusively contracting with licensed col netma to
eonslmc,3he pm*1(Sec. 70". Business and Professions Code:) The Contractor's U.
cera law data not apply to an owner of properly who builds or Improves themon, and
who contacts for such pmjeou with a contrutora) licensed pursuatn m the CanaactOel
Lk ase Law.
❑ T am exempt under Sec. . B & P C for this mum
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby sIEm under penalty of perjury oro of the following deelanlion,:
him ash will maintain a Cenifinm of Consent ro self -insure for WorkeY&Compen.
lion, u provided for by Section 3700 of the labor Code, for the performance of the -
work for which this permit is h sad.
❑ I have and will maintain Workers Compensation Insm&nm, as requited by SeNon
3700 of the labor Code, for Ne performance of the wok for which this permit I, Issued.
My Worker's Compensation Inwn-nna carrier and Paltry number art:
camer:�jTr-'s G T1Pi policyNa.:�ja�2`S�n
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This scellan aW not Meomplimd If thepermit i, foram hundred dollars HOW)
or los.)
I unify that in the paromtance of the work for which this permit Is Issued. I shall not
employ anypersan in any manrof an a u become subject ro the Worken' Compens&dw
Laws of Califamia. Data
Applicant
NOTICE TO APPLICANT: If, after radial this CeniOnte of Exemption. you should
beconm Subject to me Wooers COMPUallaA provisions of The labor Code, you muss
foMwith comply With such provisions or this permit shall he deemed awaked,
LENDING AGENCY
1 hereby aflim that there is a canwecown landingagency(a, me porman cof
esu wok for which this permit I, Issued (Sm. 3097, Civ, C.)
Name
Lender's Address
1 unify that l have read tha application and sou that we above Information is
comet. I as= to comply with all city and county andinana, and tau hws rtaling to
building construction, and hereby suthadu repreumatives of this city to enter upon The
Property for IospNom PUApoaew
(We) agree to mve, indemnify and kap harmless the City of Cupertino against
Ilabllities,judgments, cats and expenses which may in any way A. ajainsluld City
in eomequenee of the $rasions of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS
/; _x/l��L,�
Re -roofs
Type of Roof
Signuurt of A`pplicaRUC�ontraclor I D&m
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant o future building occupant nom or hendle hanNous material
As defined by the Cupenwo Municipal Code. Chapter 9.12. and the Health and Safely
Code. Sudan25532(m . IAll
roofs shall be inspected prior to any roofing material being installed.
Yes
If a roof IS installed without first obtaining an inspection, I agree to'remove
Will the applicant of froom buildingoceupana rue equipment or devices which
It haurdou air co tandMau as dcfiad by All Bay Ana Air Quality Management
all new materials for Inspection.
Wict7
❑secs
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I hove mad the hu�Nau,materiAurequlrtnrnu under Chap er6.95of dm CAlifm-
HeslN& SafnyCode Smioa,25505.25533 am125531. 1unimmused thniftiw Wilding
not cum ma y have A tenant, that It my nesprnsi day he Unify Ire oceup., of the
aircments which man W mel poor m iuvame of, Cenificate of OccupamY.
Signature of Applicant Date
4���—
All roof coverings to be Class "B" or better
Owner oroltUtbodm� Dans