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CITY OF CUPERTINO r�.
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BUILDING DIVISION PERMjy
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BUIIDINO ADDRESS:
PERMIT NO.
PALISADE BUILDERS INC
04090195
0 E 'S ME:
PERMIT ISSUE DAM
SANITARY N . EjftPOL NO.
ARCHI=JENO1NEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
t�
LICENSED CONTRACTOR'S DECLARATION
lois Description
1 hereby afOrm that I am Immune! under prowkions of Chapter 9 (commencing
With Sudo. 70(10) of Division 3ef INC flux. and Pronfwiom Cods, and my license 1.
in full fart. and.flut. ir �/ �r
License Clw UC.40
NEW CONDO -1502 SQ. FT.
Date Ghnlr o9Lit Ns.?�
ECL
ARCHITECTS DECLARATION
I understand my pla� s�used As public rtcnrda
'—
Licensed Professional
OWNER -BUILDER DECLARATION
License Law far the
I hereby .(Sent that 11. exempt (rum The fessions
alter, and Pmfusina Code: Any many or county
following reason. 71131.5, o
which mquima a permit ac enrewe4 eller, Improve, demnllitt ore any structure
annitt t.
poor tointnuance,amumquiru theapplicantf a sir
ml,casiowhtemcm
F[. Floor Area
Valuation
Conpermit
that he s(of Co LaonaCm (ChapterY
pursuant 70th)of
Sq.
mornmelkcnwit Divisio
Business and Code) or
(commencing with Section nand of Division 3 and
Ca Al edAss on, Any
Nu he k sump therefrom and the bask for du dle{od esempmon, Any violNon of
u
APN Number
Occupancy pe
Section 7031.5 by any appliunl for a permit subjects the applicant to a civil penalty of
Iml mon, than five hundred dellw (S3n).
w,
with wa{u u their sole mmnp.wness
the pmprucl
❑ L uhe
31620084.00 Required Inspections
rs 1. 1 mmeeu
WIVof
will dslhe work, and the dA
CtureBners
doraRercd(nrakpply
no ow.
and u Code: The Cantuc70r, Lt. Law rot apply lf an asvner of
Ive
q P
h. d h. .It AlmaelfedWough his
propertyImplores.
in net Intended oeoeered (or ala IL
provided that such Improvedwho Aman, intended
own Implores. that such Improvem
the within
builder Ne buildingorimpmvemanlisholdeidaneyear of completes, Can Owner.
builder will have the burden of proving that he did not build or Improve for purpose of
otos).
❑ L as owner of the properly, am exclusively contracting with licensed eontnnw to
construct the project (BCC. 7064, Business and Professions Code:) The Contrsem's U.
,
moue Law does nu apply to an owner of propeny who Gilds or improves themon, and,
who chairman for such pmjecta with aconacmrn licensed pursuant 70 site Contractor,
License Law.
❑ Iamexemplundef Sec ,Bd PCfsrlhnmaon
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of the following dularatioln:
Oh
end will maintain. Ceniaeate of Consent to selRlnsurt for Workers Carries-
utinn, As provided for by Section 3709 of the Labor Code, for the performance of the
work for which thin permit is issued.
❑ 1 ave and will maintain Worker. Compensation Insurance, As mqulred by Section
37W of the Labor Code, far Ne pencarner sof the work for which this permit Is Issued.
My Workers Compensation Insurance Canaria and Policy number w:
Canter: P2 a9Jat4J.'C 1 f&,l" Policy No.: d'-7�f
CERTIFICATE OF EK EMP ION FROM WORKERS'
'
COMPENSATION INSURANCE
(ITIS.,I. reed not hecompleted If the permit later. naMred damn (SIM)
'
or len.)
I cenify that In the Performance of the work far which this Permit Is instead, l shall not
-
employ anyperson in any manner an As to became subject o IN Worker' Compensation
Laws of C.lifomla. Data
,
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to the Worker's Compensation previsions of the Labor Code, you must
forthwith comply with such provisions or this permit shall he dcemed revoked.
CONSTRUCTION LENDING AGENCY
1 amhy alrnm that there is a construction lending agency far the performance or
the work for which this permit is issued (Sm. 3097, CO. C.)
Lenders Nanta
Under 'h Address
I cenify that I have cud this application and law that the above information 1.
COIRCL l agreC 10 Comply with .11 City Nd County hrdinaMYa and nun level muting to
'
Wading convection. and hereby attention mprnmixtiven of this city to enter upon the
'hove -mentioned property for Inspection purposes.
i (We) agree to an, indemnify and keep harmless The City of Cupertino against
I lubilldu,judgmcral and expenses which may in any way.cems against said City
In cone junco of the granting of this permit.
I APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signature of Applin 1cell 1R' Dam
12�S MATERIALS DISCLOSURE
WIII tho applicant or future building oecupaut nope as handle lux"ous material
u de0nod by IN Cupertino Municipal Code, Chapter 9.12. hod site Health and Safely
Count. Section us3z(.)n
All roofs shall be inspected prior to any roofing material being installed.
Yu
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
luurdaun air Contaminants As dented by the Bay Area Air Quality Management
all new materials for inspection.
avid?
❑Yrs /t+u
I have mW the atek✓ous mate�rialaroqulrcmenu under Chapterfi.95 ofthe Califon.
IN Health k SafslyCotic.SeNou 25505,25533 and 25534.1 i ndcnland thati(0a Gilding
does not currently have a tananl, that It is my maponsiblllly m notify site oecupal of IN
mqulrcmenu which mum be met Meth) luuance of a Cmuncate of Occupancy.
Si nature of Applicant Date
All roof coverings to be Class "B" or better
over, or.uthadved,p pate