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CITY OF CUPERTWO
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BUILDING DIVISION PERMIT
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BUIIDING ADDRESS:
PERMIT N0.
PALISADE BUILDERS INC
04090162
0 S E:
FBRMMISSUEDATE
B; CLIPERTING 14GUSING PARTNERS
999 ' ALMA STREET
SANITARY N L NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lore Description
1 beeby affil m Net 1 am licensed under provisions of Chapter 9 (commencing
with Salton 701111) of Division 3 of the Business uM Profession Code, and my license is
infullfoee.ndeffem. A $3BDy�
Lkm!�LReno Class -
NEW CONDO -1111 SQ. FT.
Dab Gonlrsem rrHac D/o lases
Ctmlo
ARCHITECTS DECLARATION
I undcrugpJ my pit �ns shall IrysedAs puhll��ard�.
Lkased Poor ..ianted r
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor', License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires A permit to ennmrocL Aber. Improve, demolish, or repair any ste cture
prier m its issuance, also requires he applicant fat such permit an rile a signed statement
contractor'Wanse Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed p ... ant to the provision of the (chapter
(commencing with Section 701)0) of Division 3 of the Business nd Profusions Code) or
Nat he h exempt therefrom and the bash for the alleged exemption. Any violation of
APN Number
Occupancy pe
Section 7031.5 by any applicant fm a permit ubjects the aPplim t 10 A civil penalty of
Out mase than five hundred doled. ($500).
❑ I.ummroftWpmpeny,mmyemployeuwlNwagnuthelrmleampewdon,
31620084.00 Required Inspections
er
ME&the work, and the,W,lYe is notmtended"offered Mr.AM(Sec. 7044, BNircu
and Profusions Cade: The Conuxetors Llano law deal fret apply b an oweof
9 P
property who builds or i m p ro u theran, and who dmuah work hi msel(or through his
own employees, provided uhatuch Improvements Am not Intended chaffered torula. if.
however, the building or Improvement is mid within on year of ampletion, Ne owner -
Wilder will have be burden of proving that he did nal Wild or Improve for purpose of
sale.),
❑ 1. as owner of the property, am exclusively cwntrading with licensed contruton b
consumer the project (Sec. 7(W, Business and Profession CedeO The Com a us's Li-
mn law deal not apply to an owner of pmpeny who Wild. or lmprovu Neem. and
who contracts for such projects with a contn.br(.) Heated p rl ant to the Cattlemen
License Law.
I am exempt under Sea . B B P C for ins, mason
-
Ower WasWORKER'S
COMPENSATION DECLARATION
hereby affirm under Nulty of perjury ane of the following decWtions
i
have and will d mid. • Ceniricate of Consent b seIFluu. fe, Warne. ComPen-
m
.mlon, uprovided for by Section 7100 of the Labor Code, for tits performance Of [bework
for which Nb permit Is issued.
❑ 1 have and will maintain Worker'. Compensation Instruct, u required by Section
37101 of the Labor Code, for Ne performance of the work for which this permit is Wald.
My Workers CnrepensNon lNurana carrier and Policy number art:
_
Canter. ggi4j&,j%iC SawC policy No:CAC*& L2SMA)
CERTIFICATE OF EXEMPrION FROM WORKERS'
'
COMPENSATION INSURANCE
(This sectio med at m completed if the permit is throw, hundred dallars(SHM)
or less)
1 certify that In the performance of the work for which this permit is loved, l siu11 not
emplay any person In any mannerm As in became subject to Me Workers'Compensation
Law. of California. Dau
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you mum
forthwith comply with such p mutons OR this permit Ihsil be darned revoked.
CONSTRUCTION LENDING AGENCY
1 hereby anlrm that them Is anatmctun Lending agency far the performance or
the work for which this permit is load (Sec. 3097, Civ. C.)
Isodose Name
Lender's Addrus
I CenEy that 1 have read Out application sent sum that the above information is
coram. l Rhee to comply with all city and county on inanannd sane In" elating to
Wilding construction. and hereby staborme Representatives of Oil city m enter upon the
above-mentioned property for iNpecuon purposes.
(We) agree to save. Mdcmaify and kmp harmless IW City of Cupertino agnWt
j liabilities, judgments, costs and expenses which may to any way accrue against said City
in s rmit.
APPLICANT Uof Me NDERSTANDS Auting, of I
ANTUN WILL COMPLY WITH ALL NON -POINT
ND
Issued by: Date
SOURCE REGULATIONS,
4eam/-05—
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Re -roofs
Type of Roof
Sij bre of AppumnUC rncbrDAM .
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or forum building occupant more or handle hazardous material
an defined by tie Cupertino Municipal Code. Chapmr 9.13, and the Health and Safely
Cade, Section 355334)7
All roofs shall be inspected prior to any roofing material being installed.
Yu
If a roof IS installed without first obtaining an inspection, I agree to remove
Will the Applicant .2t. building Occupant use equipment or devices which
Will the Applicant. roue Wilding occupant use equipment or devices which
It haurdous air Contaminants As de0ad by the Bay Arca Air Quality Management
all new materials for inspection.
Grit@
❑ Yet
I
I ham mad the husrdous, materials mquimmat. under Chspter(5.95 of the Cantor-
niaHcalNk SMmy Codc, Sections 35505,33577 and 25531.1 understand thalfthe building
deal not mmantly hem A meant, that II is my tequ.,Mlllly to nNc
otify Ilan upant of the
roquiemenu which must bemm ' r m 1110010 of A cmunceb of Occupancy.
Signature Of Applicant Date
^ e
`Daae
All roof coverings to be Class "B" or better
owneh ser .atnahimd nl