040901750
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CITY OF CUPERTINO'->
N
BUILDING DIVISION PERMIT.�G4NI2:AjC�TO,,R�%NrORMA'CIUA,
BUI IDINO ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090175
A
PERMITISSUE DATE
12
SANITARY 401-01. NO.
ARCHITECTIENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm last I w licensed under provWons of Chapter 9 (commencing
with Section 70(111) of Division 3 ofthe Business aM ProfeWmts Code, And my license is
InfallfaG.ndeffecl. gs$PJN6
ueenm cru. Lx.{
NEW CONDO -1102 SQ. FT.
Dem Contractor11f0
ARCHITECTS DECLARATION
I understandm ph shall be umdu un .-
Licensed Pmfcsaianal
OWNER BUILDER DECLARATION
License Law for the
I panty .(firm that 11. exempt from tie CnmrenCo
following mmoa ]1151.9, alter. and nm Code: Any city as count'
h, or:
aper, Improve, demolish, or mpsig any structure
which Permit t t. improve. de
a pertml re cares
,its,Wrequire.
the applicant for Such permit m ices uigned stammcm
prior to luusace, slao mqo The
Law
Sq. F[. Floor Area
Valuation
s licensed the Contractor's License (Chapmr9
(CammClltus Wlln sGlian70B)Id Division tae Bu3i11eG and PmfG3ION Cada) or
(commandit pursuant loth) pmvhision of
that he Is exempt tlmmfrom aM the basis fm the alleged eumptheo Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to m civil penalty of
not mom Nm five hundred dollars (5500).
❑ I,Uo oftMpmpeny,mmyemploymwlthwgautmirmleeompew0on,
31620084.00 Required Inspections
will do the work, and the structure i.natimended moreover foram (ice. 7044, Business
and Profession, Cede: Tie ConMcmr's Licehso LaW does hat apply m an owner of
properly, who bull ds or i m prove merman, end who dmuuc h work himm If or Ihmugh his
own employees, provided thmsuch improvements arc not Intended or offered forule. IL
however, the building or improvement Is sold within one year of completion, the owner
builder will have the burden of proving that he did and build or improve for purpose of
mI.J.
❑ 1, as owner of the property, am exclusively contracting with licensed mm3mloa in
convect tae pmjen (Sec. 7040, Business and Profession Code:) The Con soma's Lb
cense law data not apply to an owner of properly who build, or Improves memos. and,
who contracts for such projects with s canuacter(s) licensed pursuant to die Contractors
License Law.
❑ 1 am exempt uMer Sec. . B k P C (Or this amen
OwerDam
WORKERS COMPENSATION—DECLARATION
1 hereby affirm under penalty of perjury one of 'hefollowing d elaratimac
have and will maintain a Cenlfca a ofCnhmnt m ulGhrsum for Worker's Comeau.
uden, u provided for by Section 3700 of the Labor Code, for Tho p)dormance of the
work Tor which this permit Is iniad.
❑ I have and will maintain Worker's Compensation Insurance, u required by Section
3700 or me Labor Code, for me performance of the work for which this permit is Issued.
,
My Worker', Campen.stlon Insurance caterer and Policy number mm:
Carrier: A411.5, ,' Pal try He.: e2nL»25970
CERTIFICATE OF EX EM MON FROM WORKERS'
COMPENSATION INSURANCE
Mit section need Out be completed If Ile Frmit is forum hundred dollars (SIM)
err TGs)
1 certify that In the performance of the work for which this pmall It Issued, l shall not
employ any person in any manatan as in bccorat subject in be Workers' Compensation
Law. of California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this CenlOcam of Exemption, you should
became Subject m the Worker, Compensation provision of the Labor Code, you mus
forthwith comply with such provisions or this permit shall M decmcd mvnkcd.
CONSTRUCTION LENDING AGENCY
Ihereby ichthi thatmombs lending far dm Performance of
.)
' the work for which this permit Is ivuc0 (Sec. 3091, Civ. C.)
issued
Lender's Nast
Lender's AGdmu
i 1 really that I hoe read this appliGlia and .tam mm the show Information U
' comm. l agree to comply with all city a d county ordinanceund Mm hw rchtint m
Wilding construction. and hereby aumorira mpmmmstive. of his city to enter upon led
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and kap hamlet the City of Cupertino against
liabilities, judgments. cotta and expense. which may In any way seem against mid City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REOULATION
--Re-roofs
Type of Roof
Signature ofAl"Ramacomoncloe, Dam
HAZARDOUMATERIALS DISCLOSURE
Will the applicant or fume Wilding oaupantsom or MMIC hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
CMe,secdo.25532(n7 �T�A,_
All roofs shall be inspected prior to any roofing material being installed.
CYG 9 L
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or fume building occupant um equipment or devices which
It hmamnu air contaminants u dc0rmd by the Bay Area Air Quality Management
all new materials for inspection.
[Di.triclT
Yon
Idnea
I have mad the hamar materials mqulrements undcrChamer 6.95 of the Califnr.
.1. Heal" Safety Code, Sections 25505,25533 and 25534.1 understand that ifthc building
rel currently hove a rental, mm at II It my responsibility nntil'y the occupant of the
requirements which must M mel era issuance or a Cenl6Gm air Ocaancy.
Signature of Applicant Date '
il��
All roof coverings to be Class "B" or better
Owner or authorized a mal � Data