04090194U
CITY OF CUPEWfINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090194
OWNER'S NAME:
PERMIT [SUE DATE
4700
SANITARY OL NO.
ARCHITCCT2NGINEEN:
BUILDING PERMIT INFO
BLDG ELECT PLUMS MECH
O O O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Wmby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 701111) ofDAI CoA 7 of the Box.. and Professions Code, ud my ]cense Is
Lt. a°Cleana-Hect. k.g AaabgL
NEW CONDO -1502 SQ. FT.
Date Ca lose oiffn' 5jqse —
ARcurrE.CTS DECLARATION
I understand my plena Mal public mends
Licensed Pmfcesunat
OWNER -BUT LARATION
I Wmby affirm that I am exempt fmm the Contractor's License law for the
rollnwing wagon. (Section 7131.5, Business and Professors Code: Any city Of County
which eauims a Permit m commu n. atur, Improv, &act". or repair any mmetum
prior m its issuance, also require the applicant fm such permit to frit, a signed.tu ment
Law 9
Sq. Ft. Floor Area
Valuation
that Mislicensed pursuant totWprovisions o(NeContractoisLicuse (Chapter
(commencing with Section 7000),d Division 7 of the Bwinesa sed Profictim uCode) ter
Wt he is exempt therefrom and the but. for the allegW exemption. Any violatim of
ppN Number Occupancy pe
Section 7071.5 by airy applicant for a permit objects the applicant to a civil peehy of
not mart dun Ove Annular! dollen (5700).
❑ I,uowmr o(Nt property,ormY employes omit waguuds,lr tale Compenssllon,
willdo tis, work, and the structure tarot nundedwaRemd(..Me(Sm. 70th. Business
31620084.00 Required Inspections
9 P
and Pro(esmou Code: The Contractor's License Law does net apply W u owner of
pmN ny who bulla or improves dterean, sed who doeuuc h work himseIf or thmugh his
mon employees, provided dal Improvemenuare not Intended w Offered for ssla If,
however, use Wilding or Improvement Is Sold within oro year of completion. the owner -
builder will have use Wrden of provins Nu he did not Wild or improve fm purpose of
Sok.).
❑ 1, a owner of tis, pmpeny, am exclusively contracting with licensed contractors to
construct the pmjee (Sec. 70th. Business and professions Crede:) The Contractors U.
cense Law time not apply m an Owner of property who Wlla or Improve daemon. and.
whb contracts (or such pmjeets with a emtracmn(s) licensed pursuant to the Contractor's
License Law.
❑ 1 am exempt under See. . B AS P C for this mum
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby IMM under Nulty of perjury one of the following declarations:
COMMA-
him and will maintain a CtniOosm of Consent to self-Asum for Worker'sCompen-
ssint. u provided for by Section 7700 of Ne Labor Code, for the pcmoomece Of the
-
for which this permit Is issued.
❑ I have and will maintain Worker's Compensation losunnct, u required by Section
7700 of the Labor Crede. for the performance of the work for which Nis permit is bound.
My Worker's Compensation Inm ance carrier and Policy number am:
-
Carrier:aNA7'✓%)C rla<PolicyNo.;e^Iat4n.:b,ia�7g
,
CERTIFICATE OF E)(EMP ION FROM WORKERS'
COMPENSATION INSURANCE
(This section need notch completed If the Nrmb Is for onehundmd dollen (SIM)
m lea.)
I certify Not In the perfmtence of the work for which this permit is issued. I shall not
employ any person in any manner an a m beome subject m the Worker) Compensation
Law, of California, Date
Applicant
NOTICE TO APPLICANT: IL after making Ides CcniOeu of Exemption, you should
become subject to the Worker', Compensation provltlons of the Ghnr Code, you mus
forthwith comply with such provisinu a this Permit hall W dimmed mmued.
LENDING AGENCY
1 hereby drum that Nem Is ce nn lending agency Ina the performance of
s (See.
the work for which this permit 1, issued (Sec. 71197. Civ, CJ
Name
larder's Address
.
1 cenlfy that 1 have reed this application and sum that the above Information Is
I agree u comply with all city sed county ordinance, and mu law, rotating 10
Wilding construction,Wreiny s of toenurupon the
above-mentioned properly for Inspection purposes.
the City
(We) ague to outs Indemnify and tech harmless the CiCnpenstagainst
1.ave c.rdly Ad epre harmless
y liabilities. judgments, ensu and expenses which may in any way memo against Sold City
9
In consequence of the gnntrng of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Fo
Re -roofs
•]P sof Roof
Sigmunm o(Appli.%SC ntnc Das,
HAZARD S fATER1AlS DISCLOSURE
Will the applicant or future Wilding Occupant it= or handle huardoe material
u de0ned by the Cupenino Muni INI Code. Chapter 9.12. and the Health sed Safety
Coos. Section 25532(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant car (wtr Tiding occupant um equipment of devices which
I hanrdou air emumiemu as dented by the Bay Area Air Ou.Ilty Managemeat
all new materials for inspection.
r❑YesNu
Ihave read ds, ha msm,unW mqulremenu under Chspurd.95oflheGlifor-
Nullh,S
11.
Safety Cade. Smmu 25505.27577 and 25574.1 undemand Nu bids, Winting
, tot currently haw a Tenant. Ns II u my mspoosibilltY 10 may the oceupant of the
ireamus which mum W met poor m Issuance mf a Centimes, of Occupancy.
Signature Of Applicant Date
_
All roof coverings to be Class "B" or better
ns ter mmmnyed ase one