04090181CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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au ILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO04090181
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TTDF
PERMIT ISSUE DATE
E:
SANITARY R04. OL NO.
ARCHITECTAINGINEER:
BUILDING PERMITINFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I bereby affirm IMI 1 am turned under provisions M Chapter 9 (commencing
with Sallan 7M)).( Division 3.1' Ne Business Code, and my licemse b
�andpP(Qofetivao
Into `B"'' Llc.grL'-D[�
Lmcose Cis
NEW CONDO -1478 SQ FT
Dole AY ^ :e f' oc -- Ctmffsc r O A r SN L
ARCHI1ECrS DECLARATION
I undcnund my pi.... 1J{ ugpd n Puhl
Licensed Professional
OWNER -BUT ER DECLARATION
I botchy affirm that 1 am exempt fmm the Contractor', License Law for the
following recon. (Section 713 IS, Business and Profen... Code: Any city or county
which requires t permit to consumer. alma Improve, demolish, or repair any structure
prim, In i0 issuance. Rise require the applicant for such permit to file a signed statement
Sq. Ft, Floor Area
that he Is licensed pursuant to the proa visuoOf the Common's License Law (Chapter 9
that
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
IMI M it exempt themfmm and the bub for Ne alleged exemption. Any violation of
APN Number
Oecupancy'I)'pe
Section 7031.5 by any applicant for • permit subject On Applicant to a civil penally of
mut more thus five hundred dollar (M),
❑ I, as t w u r of the property, or ney employces with warrant Nelr sole compewlles.
31620084.00 Required Inspections
will do the work. and Ne auuchme town loterabolm offered forale Soc. 70". Business
ra Lineae Law donot apply an owner of
and Proration, CoThe Conusecmae m
de:
q P
property who build, m improve, thereon, and who does much wmk himself ur thmugh his
.we employees, provided Nal tech improvements are not intended oro@ted faonle. if,
however, the building or Improvement is mid within ON you of completion. the owner.
Witter will have the burden of proving that IN did nm build or Improve for pmrpmse of
,ale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contractors to
construct IM pmjeci (Sec. 7044, Bmineas arm Professions Cade:) The CoamctnM1 Li-
cense Law does not apply an an more, of propeny who Wild, or improved Ih ,mon, and.
who contacts for such projects witha eunualor(O licensed portant m she ConuaemYd
License law.
❑ lamaemptundersa. ,BAPch thtmua
Owner
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury, tone of Ne following dalantione
have and will maintain ACenifiete of Coaem to self-lasure for WorkeYtCompen-
alon, u provided for by Section 7100 of the labor Code. for Performance of the
work for which Nb permit Is issued.
❑ 1 haw and will maintain Worker's Compensation Insurance, u required by Section
of Ne lana, Code. for the pulfmmance of Ne work fa which
3700 not, permit Id issued.
My Workers Cnmpentlion Im ors. aria and Policy number are:
Carter: 14 '51: C X tiC Policy No.: C -2 33
CERTIFICATE OF EXEMMON FROM WORKERS'
'
COMPENSATION INSURANCE
(This section Red not IN completed RNe permit is fmonchundr4 dollas(g1(I()
Or lat.)
1 unify Nat In the perftnmace of the work for which this Femur Is Issued. I,MII not
employ any pumn In any manor an to en haome subject to the Warker'Corepenttion
Laws of California. Date
April cant
NOTICE TO APPLICANT: IL after making this Comfl am of Exemption, you should
become subject to the Worker, Compensation provisions of IM labor Coda you must
forthwith comply with such provisions or this Permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alfum that Nem is construction lending SuCy fonts performance of
Nt work for which this permit is hoed (Sec. 3097. Civ. C.)
Leaders Name
Lenders Address
1 1 unify Na 1 have rad Nis application am tete that IM above information id
r correct, l agree to comply with all city and county oNiarcea and este laws, misting ro
Wilding e0amalian, and Mmby auNmrim MptesenuNed of this city to enter upnn IM
above-mentioned property, for inspection purpose,
t (We) agme to um. Indemnify and keep hamlet the City of Cupertino eS,inn
1 liabilities, judgment, can and expenses which may In any way acme against said City
In I
ANTUNDEWILL COMPLY WITH ALL NON -POINT
APPLICANT UNDERSTANDS of the `Neenfing, of IAIND
Issued by: Date
SOURCE REGULATIONS,
ti'-r�'O
Re -roofs
Type of Roof
Signature of Applican nttc or Oslo
HAZARDOUS MATERIALS DISCLOSURE
WIII Na applicant or future building acupam more or handle h uardmu, material
a defined by the Cupertino Muniel I Code. Chapter 9.12, and the Halt and Safety
'
C"On"O"on 25372(,)7
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
WIII the applicant future building occupant use equipment or device which
Are. Air Quality Mtnagct
11 haxsrdnus al, comumirsut as defined by the Bay Anma
all new materials for inspection,
Inricl7 /
El yen C/�W--
I have mad the hazardous materials requltement underchaptr6.95 of Om Califor.
nia HeaIN A SafutyCf&,Secdom 255(15,25533 md25534.1 underamm thairthe homing
doe, not currently how: a term,, Nal it II my responsibility to nodfy IM occupant or the
requirement which must N met prior in Issuance cert Certificate or ampawy.
ignature of Applicant Date
All roof coverings to be Class "B" or better
Owner or authorised agent Gam
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