04090191CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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LU ]NO ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090191
N R AM :
PERMIT ISSUE DATE
SANITARY ROL NO.
ARCHITELT/ENOINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm that I am licensed umkr provisions of Chapter 9 (commencing
with Section 7") of Dlvidon Sof Ha Boom. and Proh..M. CMe, and my license is
morn fortt and efrml. B Lk.Y ,6Nb
License CI .
1g - o .�- A D
NEW CONDO -1104 SQ. FT.
Data Como
ARCHITECTS DECLARATION
I undcruand my plat, shall M w Nic reamds
Lkeusa Profcuionxl
OWNER -BUIL DECLARATION
1 hereby Milan that 1 am exempt from He Conlrurors License Lew far the
rollawing reason. (Section 7131.5. Business and professions Code: Any city or county
which requires a Pewit to Convect, alteq improve. demolish, m repair any stromupa
prior m its issuance. elan requires the applicant for such permit to rile asigned statement
Linnae Law 9
Sq. Ft. Floor Area
Valuation
that he is )Iacocca Portugal to the provisions of the Caallacmf� (Chapter
(commencing with Section 7000) of Division 3 of the Bu.ineas and Profession, Code) or
tint m k eumpl tierefrom And the bash fm dee alleged examptlon. Any vmladon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit objects the applicant 19 a civil penalty of
not more than Bve hundred dollars (1500).
❑ I, u mous of the pmpmy, m my employee with wtu u thetr vele eompenulion,
will do Ute wark. and the structure is not Intended orortered lorek(Sec. 7044, Business
31620084.00 Required Inspections
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AM Proresalons Code: The Com or's License taw dmd vel apply o Aa owner of
property who Wlld.m improws Hereon and who daosmh work himulrorthrough his
own employee. provided than such improvements Am notlnleMed m offered for ole. If.
hmvanu, the building or Improvement is old within am yeu of completion, the wnu.
Wilder will have Ute burden of proving that he did not Wild m improve fm purpose of
sale.).
E) 1. as awmr of the property am exclusively contracting with licensed monsoon to
b
ccutrwl the pe jets (Sec. 7044. Busineu.nd Prefnxiou Cade:) The CwrrumYs Li-
cause law don act apply o an owm+of PmPeny who, Wilde or improve the em, and,
cause
who emtrmot fm such prokcu with a contractor(s)licensed pursuant o He Con anar.
License law.
❑ 1 am exempt under Sec . B k P C for this recon
Owmr Data
WORKERS COMPENSATION DECLARATION
I hereby Affrtm under Penalty of perjury arc of ted following decimations
'
hew and will maintain aCeNOnuof ConsentloselFluum fm Worker. Compeer
nation, u provided for by Section 3700 of the labor Code. fm the penorname of ted
work for which this permit Is issued.
,
❑ 1 haw sod will maintain Workers Compensation morocs. u required by Section
3700 of the labor Code. fm He performgme of the work for which His Permit Is nvmn,
My Worker. Cmnpeanalion Insurance carrier and Polity number art:
Cartier. g4 A7eSi� 1W C_ Policy NO.! 2GY3M2 S33es
CERTIFICATE OF EKEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This rtminn man set he completed if Ile marth U froom hundred dollen ($1011)
or Ina)
1 cenlfy Hat in the performance of He work for which this permit h inmd, ).hall not
employ any person in my mum( u to became object lathe Workers' CmaPcnsstm
Laws of CW fomla. Data
Applicant
NOTICE TO APPLICANT': If, after making this Contftcate of Exemption, you should
become subject to IM Workers Compensation provisions of ted Labor Code, you mum
forthwith comply with tach provisions or this Permit hall be dmmed Mogen.
ONLENDING AGENCY
alit that them h c i tending agency for the Performance of
1 dear
.1 sued (Sec. 0
the war, fur which this permit Is iasmn (Sm. J077, Civ. Cd
Lender's Name
Lender's Address
.
I certify that I haw read this application AM sum dust the shove Informulun Is
I agree in comply with all city uM county ordinances and sum law paining to
Wilding connotation, and hereby emhorise mineentalive, of this city 10 eater upon the
above.memoned pmpeny for Inspection purposes.
62
(We) Agro to save, indemnify and keep hemlleea the City of Captured against
liabilities, Judgments, cwt and expenses which may in say my.came against mid City
In consequence of the gaming of His permit.
APPLICANT UNDERSTAND ND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS
Re -roofs (57
Type of Roof
2/
Signuure Of AppllnnUCon Dam
H US MATERIALS DISCLOSURE
Will the applicant of future Wilding OccuPsawore or handle Manchus material
As defined by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
de. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant o oto Wilding om:upot tau equipment or devices which
I ha'ramous air contaminants as dcflncd by the Bay Art. Air Quality MmageMenl
all new materials for inspection.
vieR
❑Yes
ldw,,
I have reed He hazardous maor al, requirements under Chapter 6.95 or the Califnr-
Health@SmclyCrAM,Sections 25505,25533 and 25534. IuMcrnand that If the Wilding
not currently hew a ono, that h Is my rdoondh U Um ratify the occupant of the
iremmuwhkhmunIm pdarmI aCmtificaoorOccupancy .
ignature of Applicant Date
Ll -4 /
All roof coverings to be Class "B" or better
Owner 1)rncrnnulho - Data