04090163C
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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090163
AM
PERMIT ISSUE DATE
E:
STREET
SANITARY 2 OL NO.
ARCNOECTIENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
P
ons of Chapter 9 (mming
1 hereby afrrm Nal I am licensed under provldmme
with Section 70011) of Division Sof the Business and Profession, Code, and my liceme in
I. full forte endaffem. t23RD�IG
License .a Lis..,'
NEW CONDO -1111 SQ. FT.
Data - Contractor A v �Rluln
ARCHITECTS DECLARATION
I undo. nylJ my plan sits
MAW puMla rtcaam —
sL —
r
LicenurProfeaeional /
OWNER -BUILDER DECLARATION
1 hereby aff on that I am exempt from the Contractors License Law for the
following reason. (Section 7031.5, Business and Professinm Cade: Any city or county
which requima a permit to consum, after, Improve, demnllah. or repair any structure
Pim to i4 issuance, also m9dms the applicant for such Permit to file a slgnad statement
Connector's License Law 9
Sq. Ft, Floor Area
Valuation
that he is licenced pursuant to the Footman. of door (Chapter
(commencing with Section 7010) of Division 3 or be Business and Prolamines Code) or
that he is exempt therefrom and the ha4 fm the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant fon permit ubjects the applicant to a civil penally of
not more than five hundred dollars ($500).
❑ I, As owner fthe properly, or my employee. with wages as lbelr able compensation,
31620084.00 Required Inspections
wllldo the wank, and lhemacmre is not lowered oroffered forsale(Sao. 70C1,13almss
and Profesalona Code: The Commune, Licenselaw does not apply Ib an owner of
q P
property who buildsm improms demean, and who doesinchwork himself orthrough his
own employes, provided thal such Imprommenu arc not Intended oro0ered forsae. It,
however, the building or improvement is old within oro year refcompletion. the owner.
bailee, wHl have the burden of proving that he did nm build or Improve for purpose of
ole,).
❑ 1. as owner of the property, am exclusively contracting with licensed conuaemn m
construct dor project (Sec. 704a, Business and Foramens Code:) The Contractors U.
cause law does nm apply as an owner of property who builds or improves thereon. and,
who cmnram fm such projects with a cmursclef.) Rcemed pursuant in the L'M4 xam's
License Law.
❑ i am mempt under Sec. . B 6r P C fm this reason
0, am Data
DECLAR
WORKER'S COMPENSATION ATION
1 hemby.fNunder .try of p do, aro of the fallowing dechndmu:
mde
have and will maintain aCenirlcae of Conant to a1f-Insure fue Wmkeh Compen-
sation, u provided for by Section 3700 of Ne labor Code. for door perfmmame of Am
-
work for which this permit Is Issued.
❑ 1 have and will maintain Workers Compensation Insurance, As required by Section
3700 of the labor Cade. for the Performance of the work for which this permit L issued.
,
My Workers Compensation Insurance enter and Policy number arc:
Center. IST 9J�S%vaG .hC Policy N..Z2
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe, Fennell I. Barone hundred dollars ($1010)
or Ica..)
I cenify that In the performance of the work for which this permit Is bound, I mall not
employ any peran In any manner an As an become subject to the Workme Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT: IL after msking this Certificate of Exemption. you should
become subject m the Worker's Compensation provisions of the labor Code, you mum
forthwith comply with such provisions or this permit call he deemed revoked.
1
CONSTRUCTION LENDING AGENCY
I hereby aiBrm that therem I. 4 a • comwnian lending gamy for the performance of
the work for which this pennll B issued (Sec. 31197, Cih, C.)
Lancers Nurse
'
lenders Address
1 I aenify that l have read this ppllrnlon and am that the above information I.
Manuel. l agme to empty with all city and county ordinances and stave lam misting m
Wilding construction. and hereby mthosike reproanmiva of this city to enter upon we
Impemlon
i ahbve-memimed progeny fm purposes.
(We) agree to save. Indemnify and keep Mnnless the City of Cuperlin, '& Aim[
j liabilities, prognoses, cuts and expenses which may in my my accnw against said City
In consequence of the granting of this Permit.
r APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC REGULATIOrs
•
Re-roofs
Type of Roof
Signature of Applica
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building accupmt store or handle haam ore material
a carload by the Cupertino Municipal Cade, Chapter 9.13. and the Health and Safely
Code. Section 35532(x)7
All roofs shall be inspected prior to any roofing material being installed.
13 yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or (future building occupant mac equipment or devices which
It havardnua air conumimnu As donned by the Bay Arca Air Quality Management
all new materials for Inspection.
.tricl1
❑YCI
1 have mW the hmMau. maufrlal. requirements under Chapter 6.95 of the Califor-
nia Health& SafolyCode, Sections 25515, 25533 and 25534,1 understand thatif the building
docs tel curtmlly hew a tenant, that It 4 my morwihilhy m nndl'y the occupant of Ow
requirements which mum N mel poor to issuance of a Cauncate of Occupancy.
ignature Of Applicant Date
1 e
All roof coverings to be Class "B" or better
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