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CITY OFCUPER'fINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
-58
PALISADE BUILDERS INC
PERMIT NO.
04090167
OWNER'S AME:
PERMIT LSUB DATE
E;
909 ALMA ST
SANITARY N L NO.
ARCHITECVFNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
ed under provons of Chapter 9 (commencing
1 Washy afErm that lam limnW
with Sec0on701aO of Division 3.1' IM Busi.uand Pro(aulom Cede.and eny license Is
in full tone end art=,. Q3I$o4 is
Llcenu Clara Lima
NEW CONDO -1478 SQ. FT.
Dan M sy u•ie py0061e e„<ia,.
ARCHITECrs DECLARATION
I undetatand my piano u p IOc records
im_
Licensed Professional v
DECLARATION
Oat
from License Law for the
,(Iran that 11..xempl from the Contractors
1 hereby I am exempt
nm Code: Any city mr mutny
following reason. (Section Ralar. and o
maso
which construct. ve, de nr.pair myttmClun
rewiesthealter.ImOrow,h
rVarrrh,
itshauax, Alsomit
poor mslcened tCl
the Wch.urrllalec signed state(Chapter
Sq. Ft. Floor Area
Valuation
palsour I. th/Irevision Of the
that he islicensedwit paramour 70ha of Division of
Code) or
sand cnselaw(Code)or
ingwith Sectlon7000) of of theBusinessexe and
(cat
hoot f3
on. Any
that he h &tempt themfrom and the bah for tin ailc{rA exemption. Any violulon of
an I.
APN Number
Occupancy Type
Section 7031.5 by any appliunl for a permit Subjects the applicant to a civil penally of
not more Nu fw hundred doll&,/ MIKE
❑ I. as owner of the property, or my employee/ with wages As their sole compenullon,
31620084.00 Required Inspections
e
will do the work. and destructors nano Intended or offered for uu(Sec. 7D44.. Busies/
an Profeu11 Cade: The Conlnnor's License Law does not apply to an owner of
9 P
property who builds or Improves Hereon, and who does uch work himself or through his
own employees, provided that such improwmeln, arc not Intended or offend for axle. If,
however, the building or Improvement I/ sold within one year of completion, the owner.
builder will hew; Ne burden of proving that he did not build or improve for purpose of
”
uleJ.
❑ 1. es owner of the properly, am exclusively contracting with licensed eonucton to
construct the project (Sec. 7044, Business and Professions Cade:) The Colnramrs Lb
cense Law does not apply to an owner of propeny who builds or Improves Neem. and,
who contracts for such projects with a conmsemr(&) licensed pursuant to the Contactor'.
Lkense Law.
❑ Iamexemptunder Sea .B&PCfarthnseuun
Dau
WORKER'S COMPENSATION DECLARATION
Oar
1 hem ry.farm under penally of perjury am milk following declarations:
ham and will maintain.ConificauofConsent Iosel6imure forWmkefsCumpen.
n, u provided for by Section 3700 of the Labor Code, for due performance of the
Zfor which dui/ Permit b laved.
❑ 1 haw and will maintain W.kcB Compensation Insurance, u required by Schon
3700 of Ne Later Code, fm due performance of tin wart for which Nis penult i/ Issued.
MY Wbrkefa Cnmpematian Insurance carriar and Polity number am:
Cartier. Policy No:JXCATEiF
EXEMPTIONFROM WORKERS'
'
COMPENSATION INSURANCE
(This soml. Iced not N completed lithe permit I/ (more hundred dollars (SIM)
or lb,"')
1 cenify the, In the perform... of the work for which ml. Permit It Owed, i Wall nm
'
employ any person in any mannerm u to become subject to lha Worlurt'Compemni.
laws of California, Dale
Applicant
NOTICE TO APPLICANT: if. after making this Cenifiute of Exemption. you Would
become /object ro the Worker'/ Compensation previsions of Ik labor Cade, you mull
forthwith comply with such provision, or this Permit Watt M deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hemry aRrm that there Is construction lending agency far the performance of
the work for which this permit I/ Issued (Sec. 3097. Civ. C.)
Lender's Name
Lenders Address
j I mnily dust 1 haw mad this application and sum that the above Information Is
correct. 1 agree to comply with all city and county ordinances and mule laws relating to
building convection, ind hereby stalwart mpr.semstiw. of this city to enter upon the
about -mentioned property for lnspecdon purpose/.
(We) ague to save, indemnify and keep harmless the City of Cupenino against
j loblli0e/,judgmonts,com and expenses which may In any way.acme against old City
I in connegnence ofthe granting m(thIs perm It.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
•lP
rt ItSe"t/
sign.um arAppuc. nmrselor Dote
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building occupant store or handle huarCous material
As refund by the Cup mm. Municipal Comic, Chapter 9.13. mJ the Health and Safety
Cote, Smile. 25533(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
It hnallous air concern as doll d by the Boy Am. Air Quality Management
all new materials for inspection.
District?
❑ Yes
I hivemad lie hanrd.smateriW nquiremeno mularC'Iupter6.95 ofdur Collins.
me Health Sectime,23305,25533 and 35534, 1 undemsttd lhulfNe Wilding
does not currently haw a tenant, dial it u my respomihlliry, m nodfy the occupant of the
Iequimmenu which mu Ie met met ppoor m Issuance or certificate of Occupancy.
Signature of Applicant Date
6 -'Z1 A
All roof coverings to be Class "B" or better
Owner or nuhho i d—agent Date