04090179ia6
pt
CITY OF CUPERTINO
"T1
BUILDING DIVISION PERMIT
1aC0N," ,CTOR�T,,1V,VU
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090179
OWNER'S NAME:
Ong ALMA RTREET-
FERMITLS'6UEDATE
frizo) 4U-4700
SANITARYNPARTNER2 LNG.
ARCHITECT'ENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
oP
1 hereby afllrm that I am licensed under provisions m Chapter 9 (commeocin{
with Section 7010q of Divldon 3 of the Business and Professions Code, and my license Is
mean force and erral.F3sR6v/�
cense Class '6 Like.,
LiL
NEW CONDO -147.8 SQ FT
Date Ad - A y -e gra Contractor
ARCHITECT'S DECLARATION
1 understand my pt used u
Licensed Professions
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from Ne Contraclofs License Law for the
following roman. (Section 7131.5, Business and Professions Cade: Any City or County
which require, a permit to enmwer Alar. Improve, demolish, Or repair any alructum
prior fit itsIssuance, also requires the applicant for such permit to file a signed statement
Contractor's License law9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant In the provisions of the (Chapter
(commencing with Section 7000) of Division 3 of the Business and Profcminn& Code) or
that he Is exempt Mcmfrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permtuubjecu the applicant to a civil Penally of
not mom than five hundred dollars ($500).
❑ I, As owmr of the property, ter my employees with miles As their sale compensation,
31620084. 00 Required Inspections
will do the work, and lheatruetum is not informed or offered (mad. (S.C. 7044, Business
and Professions Code: The Communes License Law dean oat apply to in owner of
9 P
pro pony who builds At Improves themon. and who does such work himself or through his
awn employees. provided that such Impluemenu see not landed or altered IN sale. if.
however the but ldleft or Impmwmant Is sold within am Sear of completion, the Owner.
hall&, will have the burden of proving that he did not Wild As Improve far purpose of
sea).
0 1, as owner of me property, am exclusively contracting with licensed contractors he
construct the project ISec. 7M4, Business and Professions Come:) The Contractor's LL
cense law alms not apply to an owner of property who builds or improv themon, and
who contracts for such pmjecm with a contractor(&) licensed punont to the COnl.clor's
License Law.
❑ l am exempt under See. Bk P C fm this Amon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby afftrm under penalty of perjury ON of the following declarsINS:
I have And will maintain A Ceniftmk of Consent to self-imum for Worker's Comem
p
sstlon. u provided for by Section 3700 of the labor Come, for the performance of the
work for which this Permit is ist
❑ 1 haw and ME rummaln Workers Compensation Insurance, u .quinti by Section
3700 of me labor Cade. for da performance erformce of the work IN which this permit is imaed.
My Worker's Compensation Insurance carrier and Polity number see:
CaMec. 91.41e S i:r Policy No.: 3
,
CERTIFICATE F�P1ON FROM WORKERS'
COMPENSATION INSURANCE
(This {cellon need not becomplcted If Ibe Permit W Amonc hundred dollars ($1010)
or les{J
I citify that In the perfom once of the work for which this Permit Is Issued, I shall not
employ any person In any manner so u as become subjxl la IN Worker{' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT. IL afar making this CCnIBt&IC of Exemption, you should
become subject to the Worker's Compensation provisions of me labor CAN. ynu mot
,
forthwith Comply with such provisions m this Permit shall be Named revoked.
CONSTRUCTION LENDING AGENCY
I WAby affirm that the. i,, Conmuction lending agency far the pattern. of
the work fur which this permit Is iumd (Sec. 3097. Civ. C.)
lames Noma
lander', Admmx,
j 1 certify that I haw and this application AM sunk that me above Information is
' Corset. I lame to comply with all city and county ordinances and man law, raising ID
building con&Immloa, and hereby suthodA representatives of mi& city to enter upon the
ahovomentiumd property for Inspection purposes.
(We) agree to sew, indemnify and keep hmmless the City of Cupertino against
i liabilities. judgments, emu And expenses which may in Any wry accme against odd City
uencI APPLICANTOUNDERSTANDS IAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. -
Re -roofs
Type Of ROOF
-2✓'
��
Signals. of AppllaMCNuumr DAN
RIALS DISCLOSURE
HAZARDOUS
Will tiro applicant N (marc building occupant store or handle hazardous material
As defined by the Cupertino Municipal Code, Chapter 9.12, and the Halm and Safely
caM,eaxss3z(.)7
All roofs shall be inspected prior to any roofing material being installed.
0 YeaNo
If a roof is installed without first obtaining an inspection, I agree to remove
Will the aPPlicantor fulureWli din{occupanlufo cyvipmenl mdevlces which
It huardnus alr mntammanu As de0nnd by the Bay Area Air Quality Mutagement
all new materials for inspection.
WiC14YesI
have mad the hazardous material& Aquirementa under Chapter 695 of the Calif r.
Id"',....
Health it Safely CMA, Smdam x5505. x5533 And x5534.1 umlerdand met If the building
oat curtnlly hew a tenant. met It u my maponslMtily te Andly the occupant of me
mamcm which must be met prior m issuance of& Cerdnmk of Occupancy.Signature
Of Applicant Date
All roof coverings to be Class "B" or better
ner urwmari' col Dma