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CITY OF CUPERTINO
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BUILDING DIVISION PI•JRMIT
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BUILDADDRESS:
PALISADE BUILDERS INC
PERMITN'04090166
'04090166
A
PERMIT ISSUE DATE
E. 11GUSING PARTNERS
909 ALMA STREETSANITARY
O. CONTROLNO.
ARCHITECDENOINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 homey affirm that 1 am licensed under provisions of Chap to 9 (commencing
With Section 7000) of Davison 3 of the Box .and Prafmanna Code, and my license I,
IntoLkenlse Cl"fmmm nd often- Lm.g � °N
.NEW CONDO -1478 SQ. FT.
Dau O Canchar" 501i&
ARCHrmcrs DELLA ATION
I understand my pla2aJM11 le ued akRl Alit rtcmda
Licensed Prnfeasinnsi
OWNER -BUILDER DECLARATION
1 hereby .(Siem that I License law Ity
from the Cssions
I.S.exempt
o co
following mason. 703 nv Code: Any airy or county
and Parn.
mit
etrBraine.
plot improv, den NAILt or repair any
which e t (m
which •permit
ne uirutmel, atOctam
its tum also requires IW Applicant such r m Bk signed saturated
prise u its Tanned
Sq. FL Floor Area
Valuation
that i coo' s U.tsio(Chapterod)or
atho ttheBlncmiaLlmne
me ccenwitpursmnllo0epm Division Cade)or
(commencing CZgwishseNon70W) NDivision3 of the Budnexemton,
0 9 3
An vi
Rol he Is eaemp therttrom aM the buts for the sileged eabmptlon. Any vinlNon at
APN Number
Occupancy Type
Section 7031.5 by any Applicant for a permit Subjects the applicant 10 A Civil penally of
not more than five hundred dollars (55007.
❑ 1, As owner of the property, or my employe" with Wigan their sale ampensston.
31620084.00 Required Inspections
will dei the work, and lheavucwre Ism,intended proffered forasm(Sec. 7044. Business
and Pretensions Code: The Co ram serf License, Law dome, ant apply to an own" of
9 P
property who hullda or improves thereon, and who docsiuch work himself or through his
awn employees, provided that such Improvements are not Intended oroReed f" ale. If,
however, the Wilding or Improvement is said within mu year of campleuon. the owner.
Wilder will be. be burden of proving that he did not build or Improve for purpose of
"u,).
D L" owner of the property, pm exclusively contracting with licensed contractors to
wnstmcnhe project (Sec. 7044, Business and Professions Code:) The Contractor's Lh
cave law docs not apply to an owner of property who Wlldn or Improves thereon, and
who contracts for such pmjecm with a evuacur(s) licensed pursuant to W Contnetora
License law.
D l .m e.empi under Sec. . B h P C fnr Ml, eason
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of the following Limitations:
have and will ..]main a Certificate of Conant to elf-Innum for Worker'Compen-
.lion, As provided for by Section 37011 of the labor Code, for the performance of the
work for which this permit is issued.
D 1 have and will maintain Worker's Compensation Insurance, As required by Section
3700 of the Labor Code, for the perfomtmce of Ne work fvwhlch this pmrmll Is Issued.
My Wnrkeh Compensation Insurance "Surer Susi Policy number Ain:
Cartier. M1NvitS11G 7WL POIIry No.vr3HK01RZL6$
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(rhes sectan =door W completed If Me Immlr is toroa hundred dollar, (Slag))
Or kap
1 cenify Nn In the peofmmanee of the work for which this Permit B Issued, I shall nut
-
employ anypo stn in any mann" an AS la become subject o the Waken' Compensation
Law of California. Data
Applicant
NOTICE TO APPLICANT. If, after making IMS Cer iOnu of Exemption, you should
become abject to the Worker's Compensation provide" of the LAW Cade, you mum
'
forthwith amply with inch Provisions rte this permit MAIL W deemW invoked.
CONSTRUCTION LENDING AGENCY
1 bemby affirm Meal tett In a construction lending agency far Me performan" of
Me work fm which this perm0ls issued (S". 4497. Civ. C.)
Lenlees Name
LenderSAddmas
1 1 <"tify that 1 bee, mad thts application and sue door the above information Is
enmea I agree At comply with all city and county on inunces and Sue laws relating to
building constriction, and hereby au hone representatives of this city to enter upon the
above-mentioned property for inspection pugmea
(We) agree to an. indemnify and keep bvmless IN City of Capetian against
j liabilities,judgmenW coats and expenses which may In any my eenu aSainstuid City
In I
APPLICANT UNDERSTANDS Aence of Me Starting of thIND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Z -O
Sign MO.e fAppll .t Com... Data
HAZARDOUS MATERIALS DISCLOSURE
WIII the Applicant Or future building Occupant alma or handle hvardaua material
'
As dented by IW Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
Code. Section 25532(A? �`
All roofs shall be inspected prior to any roofing material being installed.
Dyes Jed
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment or devices which
It hanrdnv it cnm.minanu"deMcd by the Dag Arca Air Quality Management
all new materials for inspection.
District?
❑Yes _dtlo
1 have rota the hevardd..smau\ri.lanquimmenu underChapur6.95 of the Celifor-
tie Health&SafetyCode, Sections 25505,25533 and25534. 1 undcrsund thelium Wilding
does rat curtenlly have a mmu t, that B Is my uapovlMlOy At nal I'y the Occupant of the
mquimmcnuwbichmuklWmelpdormlmsuanccofa C"dncakof Occupanry.
ignature of Applicant Date
All roof coverings to be Class "Bo or better
Owner tar authorl'r, mn1 Dau