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CITY OFCUPERTINO
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BUILDING DIVISION PERMITQA\4S
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BUIIA]NO ADDRESS:
PALISADE BUILDERS INC
PERMIT N0,
04.090174
AM
FERMTrISSUEDATE
(660)479 4700
SANITARY OL NO.
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Section 7") of Division 3 of the Business aad Profession, Code, and my license is
in full force and effect. jil �,�06y�
Clas LIc.N O
NEW CONDO -1478 SQ. FT.
Dau — o umractor
ARCHITECT'S DECLARATION
I understand my plans hall W used bit
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affrw that 1 am exempt from the Contractor's License Law for the
following mason. (Section 703 t.5. Business and Profn.m. Cole: Any city or county
.
which requires a pewit to construct, alter, Improve, demolish, tar repair any mrature
prior In its WUaMT, also requires the applicant for such pewit to file a signed summent
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant o the provisions of the Contractor. License Law (Charter 9
(commencing with Section 7") of Division 3 of Me Business and Professions Crede) or
Met he is exempt therefrom and the basis for the alleged exemption. Any violalon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a pewit subjects the applicant to a civil penalty of
not more than five hundred dollars (5300).
[-11, u owner of the property m my employees wit wages u Ussr sole compenudw,
31620084.00 Required Inspections
ener
will do the weak, and thesnucmm is not intended ordffemd forsau(Sec. 704E Business
and PmfdW.0 Code: The Commaloes License Law dao not apply to an owof
9 P
property who bu ilda ter Improves demon, and who das such work himael f or through his
own employees, pmvlded that such Improvemau are not intended muttered for ale. If.
however, the building or improvement Is sold within one )ear of completion. the owner.
builder will have the burden Of proving that he did not build Or Improve for purpose of
sale,).
❑ 1, as owner of the property am exclusively contracting wish licensed eomncun to
consumer the pmjem (Sec. 7044, Business and Professions Code:) The Cconmtor's U.
cense Law does not apply to an owner of property who Wilds or Improves the con, and
who contracts for such projau with a eontr000r(s) licensed potatoes to she Cdnsacton
Lmm m Law.
❑ lamexemptundiMSec. ,B&PC(orthisrtuon
Owusr Dau
WORKER'S COMPENSATION DECLARATION
affirm 1 Mmby arm under penally of perjury ous Orth s fallowing declarations:
1 have end will maimdn a Certificate of Cnnmm m self-Iroum for WorkefsCompen-
sation. as provlMd for by SaOOn 3700 of the Labor Code, for the pedowance of the
work for which this pewit Is issued.
❑ I have and will maintain Worker's Compensation bsurance, as required by Section
3700 of the Labor Coro, for she performance of the soak for which Nis Pewit is issued.
My Worker Compensation Insurance carrier and Policy number am:
Cartier. I{ d2h 2 %%f Z•tifPoltey No.: Z2 000VIa2 6 a 30
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section used nos W computed if the pewit is for oushundreddolian (SIM)
or loss.)
I cenify that In the performance of the work for which this Permit is Issued. I shall not
employ anypermn in my manners as to become subject o theWel eri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. It, after making this Certificate of Exemption, you Mould
become subject to the Workers compemtion provisions of the hakes( Cock. you muss
foMwim comply with such provisions or this pewit Nall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that siert las conrmam. lending Scary fm the performance of
Me work for which this Permit is issued (Sec. 31197. Civ. C.)
IsndcYs Name
Louden Add.
1 certify shat 1 have read this application and sum WI she above Information Is
comm. l .1. to empty with all city and county OrMormeund sum hon misting he
W ildingconstmnion, and hereby authodre represemuivea of this city to enter upon the
ahove-mendonW progeny Tor inspection purposes.
(We) agree to save• indemnify and kap bawled the City of Cupenin t again
j liabilities, judgments, costs and expenses which may In any way amve against wd City
I. cmuequeme of she gnnung m(this pewit.
I APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATION:s
e -roofs
Type Roof
� �
Signature of APPIicanUComrantor Dau
HAZARDOUS ATERIAIS DISCLOSURE
of
WIII the s material
or future Wilding oeeupant sure or lu lMe
Health
as defiusd by iW Cupertino Munidryl Code. Chapter 9.12, and the Health and Safety
a Cupertino
code, Section 25532(.)7
Yea
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant a future building deedless um equipment or devices which
b hanrdous air conssmlmods as defined by the Bay Area Air Quality Management
all new materials for inspection.
esict7
❑Yes
I have read the hasardous materials requirements under Chapter 6.93 of McCelifor-
1�qummcn
Health&SalnyCode,Seetimu 23305.25577 and 255N.1 underaWal thaifde Wilding
s rot currently have a stunt that It u my MMOMIMlity M adfy the acupanl of Me
ts whkh be metpnmmi:mnnm dr._a��Pry.Signature
of Applicant Date
All roof coverings to be Class "Breor better
ner or authorized ag Date