04090170CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
;CQNTI2ACTOI2INk'fJI2vIATIQN,
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT ND. 04090170
OWNER'S NAME:
PERMIT ISSUE DATE
4�20&Mnk
SANITARY N9 NO.
ARCHITECDENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Description
lob De p
I bmaby of iron that I am licensed under previsions of chapter 9 (commencing
with Scallnn 7")of Division S of de Business And Professions Code, and my license is
'
Inc full farce and efracl. ,•j eY (e
License Class Llc.g
NEW CONDO -1102 SQ. FT.
Dale �/-1/-o Contractor 7
ARCHITECT'S DECLARATION
1 undemand my om.,lb be used a
Licensed Professional
OWNER -BUILDER DECLARATION
I herehy affirm that I am exempt from the Conitamar, Licnnse Law for the
r.
following mason. (Salon 7131.5, Business and Professions Code: Any city ase county
which require. a Permit to emmmet, alter, improve, demolish, or repair any structure
pilar In its issuance, also require&the applicant rat such Permit to Ole asigned statement
Contractor's law9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant it) the provision of the cense (Chapter
(commencing with Section 7800) of Division 5 of the Business and Professions Cone) use
that he is exempt therefrom and the basis for de alleged exemption. Any violation or
APN Number -
Occupancy Type
Salon 7071.5 by my applicant far a permhanbjeets the applicant to a civil penalty of
.at owe Nm five hundred dollars ($500}
❑ Las owner cribs property. or my employees with wage, As their sole mmimmundon.
31620084. 00 Required Inspections
will do ON work, and the mature Isnot mlendedoraaend forsale(Sec. 7044. Business
and Profession, Code: The Continuer's Liam Law does not apply a an owner of
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property who builds or improves thereon, and who doe.such wok himself or through his
own employee.• provided thal such Improvements ase not Intended oro@sed torale. IL
however, the building or Improvement is Gold within am year of completion. On owner.
builder wig have the burden of proving that be did not build or improve for purpose of
sale.).
❑ 1, a answer of the property. am exclusively contracting with demand Nannette; to
construct the project (See. 7044, Business and Profusion Cede) The Comoros'. LL
cents law does not apply in an owner of property who builds or improves theean. and
who concocts for such projects with a eonumror(.) licensed pursuant to the Contractors
Leena Law.
0 1 am exempt under Sec. , B & P C for this Mason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penally of perjury ON of the following de,latasiom:
Iluveend will maintain a Certificate of Conant to alf-imme far Wmker'.Compen-
alion, As provided for by Section 57M of the labor Code, for Ne performanm of the
work for which this permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance. As required by Section
7900 of Ne labor Code, for the performance of the work for which this permit is Issued.
My Workers Compensation lmutance artier and Policy number Am:
Cartier. AIAJ'l'<J7i ✓C PoIIry
CERTIFICATE OF EXEMP ION FROM WORKERS'
COMPENSATION INSURANCE
(Thin seellm need not W compleed If the Permit Is foronc hundred dollars (SIM)
or Ices.)
1 cenify that in the performance of the work for which this Permit la issued, I shall not
employ any Person In any manmrso as in became abject to the Workers' Campenadon
Laws of Calif ntla. Data
Applicant
NOTICE TO APPLICANT: It, after making this Certificate of Exemption, you should
become subject m the Worker's Compensation provisions of the labor Code, you must
forthwith comply with such provisions or this parmil .hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby afrtrm that there N. construction lending agency fm the Normonace of
the weak rase which this permit I. iamd (See. 3WL Civ. C.)
lender's Name
Lender'. Add.
'
1 certify that I have red Ial.applic Ulan and me that Ne shave Information Is
correct. 1 agree in comply with all city and county ordinances and time laws mining to
building convection, and hereby anthorise representatives of this city ro enter upon the
above-mentioned property for inspection purposes.
(We) agree to ave. Indemnify And keep harmless the City of Cupenino against
j liabilities. judgments, tom and expenses which may in my way acme agaimltud Ciy
In eonxgmme of the Standing of this permit.
1 APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
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—
Re -roofs
SI{nawrc ase ApplleanVC mor Dam
HA ARDOUS MATERIALS DISCLOSURE
Type of Roof
WIII the applicant or future building occupant store or handle hoard... Maerial
As dented by the Cupertino Municipal Code. Chapter 9.17, and the Health And Safely
Me. Smile. 25552(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑WS
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant o future building occupant um equipment or device, which
It haurdaus all contaminants As defined by the Bay Ante Air Qmlily Management
all new materials for inspection.
stricl7
Imquiremcros
❑Yes v®'f111"
I have mall the INvaadm. manna), requirements u ntler Chmic,6tha 95orCalifon
ni.Halm&Saf lyCode• sectors,25503.25555 Ad 25555.1 udennrW that if the building
dues cel C..all, hew a Nast, that It u my mapamibllily, a Mary the occupent sof the
which mum be met atissusm ora agcy.
Signature of Applicant Date
2�-
All roof coverings to be Class "B" or better
Owner unulhmiredage sti Delc