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BUILDING DIVISIONPERMIT
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BU IIAING ADDRESS:
PALISADE BUILDERS INC
"Ah""o04090180
N R AM
PERMIT ISSUE DATE
SANITARY O. OL NO,
ARCHITECnENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lois Description
1 hereby .flem that 1 am Itcenwd under provision, of Chapter 9 (commencing
with Schon 70({))of Division Sof No Business and pomeml... Code. and my license is
In full force and effect. tfsg 6 k
License Clus 1.1.16
NEW CONDO -1478 SQ FT
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Dem C'm
ARCHITECTSS DECLARATION
I understand my Place At ha used
Licensed Ponicaumal Tz
OWNER -BUILDER DECLARATION
I hereby alarm that I am exempt from the Contractors License Law for the
follnwin{ reason. (Section 703 1.5, Business and Pwfeuions Code: Any city or county
which rtq.1. a panmll In conouer, aiteq improve, demohah, m rtpair any Owlure
,
poor to he issuance, also requires Me applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that be is licensed pursuant to the previsions of the Contractor's License Law (chapter 9
(commencing with Section 7000) a Division 3 of the Business and Pwrculans Code) or
Nn ha Is exempt therefrom and Ne bub for the alleged exemption. Any viobllon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a pemdl objects tie applicant to a civil penally of
not more Nan five hundred dellen ({300).
❑ 1, As owner of the property, army employees with wages As theiranlo compensation,
31620084.00 Required Inspections
will do tin work, and themaua3um is not Intended nroQenl foraaN(Sec. 7011. Business
And Professions Code: The Comember's License Law COCA ret apply in An owner of
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property who builds or Improves thereon. end whodoes such work him elf or through his
own employees, provided that such improvements Are not Intended oroRered for sale. IL
however, the building or Improvement Is sold within one year of Completion, Ne Owner.
builder will love the burden of proving that W did not build or improve for purpose of
W..).
❑ 1, as Owner of the property, am exclusively contracting with licensed com unnra to
construct ha posed (See. 7044. Business and Professions Code:) The Contractor's Li.
cense law docs not apply to an owner of property who builds or Improves Ihenon. and,
who contract, for such project, wide a contrwmr(s) licensed Pursuant to the Com exam's
License Lew.
❑ 1 sec exempt under Sec. . B A P C for this noon
.
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby eflbm under penally of perjury one of Ne fallowing decl.n0ons:
'
new and will maintain •COA6este of Consent to self -Insure for Worker's Compcn-
ntian, As provided for by Section 3700 of the labor Code. fm the Performance of the
work for which Nb permit is lamed.❑
1 have and will maintain Worker', Compensation Insurance,As required by Section
3700 of Ne Labor Code. for the Performance of the work for which this Tamil is Issued.
My Worker's Compensnlo i Insurance artier end Policy numncr arc:
'
Caller:^43w ,'1f' Zdg' Polley No,:C.Z0CCAQ:1L3
CERTIFICATE OF EXEMPTION FROM WORKERS'
.
COMPENSATION INSURANCE
(This section need not be comple ted a the permit is fm ow hundred dellen ($1001
or Ices.)
I certify that In the performanea of the wart for which this permit is issued, I Nail ma
employ any person In soy manner an As to become subject to tis Workers COmPensstloct
Laws of California. Data
Applicant
NOTICE TO APPLICANT. If, after matin{ this Certificate of Ffempitem, You should
become subjml as Iha Worker's Compensation provisions of the LxM Code, you must
foMwith comply with gush Provisions m this Fenced shall ha deemed evoked.
CONSTRUCTION LENDING AGENCY
I nonny.Rrm that don is conslmctinn lending agency for the performance of
Ne work fur which this permit D issued (Sec. 3097, Civ. C.)
Lender's Name
lender's Address
I ceulfy that I have read this application and male N,I de above Information is
comet, I agree to comply with all city and county ordinance, and state low. misting to
building construction. and hereby.mhorm representatives of Nis city to enter upon the
above-mentioned pmperty for inspection purposes.
(We) agree to save, Indemnify and keep harmless the City of Cupertino against
liabilities. judgments, tomo and expense, which may In any way acerae against mid City
in coneephonce of the MIL
APPLICANT UNDERSTANDSranting Of IANhisD WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS. -
Re -roofs
Signature of ApplicanData
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will then applicam or future Wilding occupant pore or handle huemom material
as defined by the Cupertino Municipal Code, Chapter 9,12, and the Health and Safety
Cade. Section 25532(07
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the aPPll=act((((or fumm bre { ottupam sax cyulpmem m device, which
it haramou.air Contaminants As dented by the Bay Ama Air Oua1hy Management
all new materials for inspection.
twin]
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I have rote the h Nems materiels requirements under Chapter 6.95 of Ne Callfor.
rain Health A Safety Code, SeNe.25505,25533 end 25534.1 undenond Nal If the Wilding
does not currently hew a accent, that It is my responsibility m notify the occupant nr the
requirements which must W met prior to hmance oft CcrdOcam of occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorized agent Dam