04090197CITY OF CUPERT[NO
BUILDING DIVISION R
PERMIT
CONTR:ACTO�N'FO�A"CIU1V^
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BUILDING ADDRESS:
q01 STEVENS GRK
PALISADE BUILDERS INC
PERMIT NO. 04090197
# 221
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY N OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hemby affil m that 1 am licensed under provisions of Chapter 9 (commencing
who Section 700x) of Division 3 of the Business and Prefemon$Cnde, and my license I.
In (all force and ellen. n
NEW CONDO SQ. FT.
LicensoC Lic.g����
-1502
—
Dem eastontm nL., S,,I �—
CHRIECrSDECLARATION
I understand my plan[ $hall puhllc rten
L"Mad Professional
OWNER -BUILDER DECLARATION
I herchy affirm that I am exempt from the CnurumM1 License Law far the
following reason. (Section 7031.5, Business and Professions Code: Any city at county
which myulm • ponat m ematmet. site,, Improve, demnitsh, nr repair any ca.h m
'
prior to Us IYunnCC, Also myalrta the aPPHCAM forsuch permit to Ida a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed Imumt to the provialonaof the Comrumr's License Law (Chapter 9
(commencing with Section 7000) of Division 5 of the Business and ProlasWn$ Cade) m
Nat he Is exempt thertfrum and the buts for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7051.5 by any applicant for a pemdl subjects the applicant to a Civil Penally of
not more than five hundred dollar ($SW).
0 1, u owmr of the pmpeny, a mY emPloyees with wges u than ole compewdon,
31620084.00 Required inspections
P
will do the wark,and thesmucmn is ml intended eraaesd forsain(Sec. 7044, BuNrcu
Code: The Conrm(s License law docs tet appy m an therms of
and Profession u
q
property who Wilda or impove$thermn.snd whodoes such work hlmselfor through his
Own employees, provided! Nn each improvements ane not Intended erortertd fm We. If,
however, the building or Improvement Is sold whole am yeas of completion, Ne owner.
builder will have Ne burden of proving that he did nm Wild or Improve for purine of
cab.).
0 I, as owner of the property, am exclusively contracting with licensed commuters m
convect the project (See. 7044, Business end Pinfeeeiou Cade:) The Connector's Li.
came Lew dont not apply an an owner of property who Wilde or Improves themon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Comnctoes
License Lew.
0 1 am exempt under Sec. . B & P C for this reason
Owner Dau
WORKERS COMPENSATION DECLARATION
1 bere ey affirm under penalty of perjury Om of the following declextiom:
wand will maintain a Cerdfhcae .(Conan. rose]!-luum for Worker'$ Canem-
asrlon, u provided for by Sudan 37W of the labor Code. fn the pedormaae of Me
woo for which this p rmit is issued.
0 1 have and will maintain Worke s Compensation Iasu once, as myulmd by Section
37W of the labor Code, for the Performance of the work fix which this permit os Issued.
My Workers Co nKout m Insurance carrier atW Policy number art:
Carrier. MJ't Tfv� Policy No.: r2etenda.26'�
CERTIFICATE OF P-XEMP170N FROM WORKERS'
COMPENSATION INSURANCE
Mis Auction need notbe completed IrIM Permit Is forom hundred dnllus (SIM)
or Ice,)
1 coolly that In the performance of the work for which this permit is Issued. I shall not
employ any penin in my manner an As an become subject or tW Worlsen' Compensation
Laws of California. Data
Applicant
NOTICE TO APPLICANT. If, after making this Cenificste of Exemption, you should
bcewne subject in the Workers Compensation provisom, of Me Labor Code, you muss
forthwith Comply with such provisions or this permit shall be deemed rewind.
CONSTRUCTION LENDING AGENCY
e agency for the Performance of
1 herby Nn there las construction lending
ichthi
30 7,
Me work la which Iola permit Is loved (Sec. 3097, Co.Civ. Cd
Lender's Nano
Lcndcts Address
I cmlfy than I have rtAd Nle appllestion end Num that the sWve Information la
correct. l agree to comply with All city and county ordinances and aur owe misting to
Wilding convection. and hereby authmin representative, of this city to enter upon the
i above-men0oned propeny for inspection purpouN.
(We) agree to save, indemnify and keep hatmleas the City of Cupertino against
j liabilities,judgments. eases and expenses which may In any my acerae against said City
1. i APPLICANTeof the Inenting of UNDERSTANDS AIND WILL COMPLY WITH ALL NON-POINr
Issued by: Date
SOURCEREGUL S.
Re -roofs
Type of Roof
Sipain.of Appii.AUCo f Data
HA DOUS MATERIALS DISCLOSURE
Will the applicant or forum Wilding Occupant lore rehandle haurdeus material
As defined by the Cupenino Municipal Code, Chapter 9.12, and the Health and SONY
Coca, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ YCN
/future
/future
If a roof is installed without first obtaining an inspection, I agree to remove
building Occupant use equipment or devices which
Will the Applicant building occupant use equipment a devices which
Will the Applicant
hautdou$ air contaminants As dermad by the Bay Area Air Quality Management
all new materials for inspection.
mia1
Dyes .
I have mW the hannloa[maknish oup,lamenuunde1091te145,95ofthe Califon
Cis Health&SafetyCode. Sadao 25505.25533 And BIN. I mxlersmhd thNillM Wilding
rima not currently hew a rennet. that p It u my rurismillry to madly the oCAWam of tie
myulmnxa. wh ht W met poor m issuance Ora Cenincste of Occupancy.
Signature of Applicant Date
y -01—
All roof coverings to be Class "B" or better
Owner or mihoHnd agent Date
C