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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT No. 04090198
OWNER'S NAME:
PERMITISSUEDATS
SANITARY N0. CONTROL NO.
ARCHITECTIENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0
LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 hereby affirm that I am licensed under Patricians of Chapter 9 (commencing
with SentWn 70(10) of Dividon ] e(Nc Bmdneaaad Pabfcadnns Cods, and my Iiccnw is
in full force and air=.
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NEW CONDO -1502 SQ. FT.
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ARCHITECTS DECLARATION
1 underwnJ my Placa shall No public rttnr�—�_
Licensed Professional � x
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contnclafs License Law fat the
following maven. (Section 71131.5. Business and PmfeWmis Cade: Any city Or county
which mqulmv a Pennll Int cormmcl, aim, improve, demolish. a repair any atnewre
prior an its issuance. Also requlrce the applicant for such permR to file asigned,tstement
Contractor's License Law 9
Sq. Ft. Floor Area
Valuation
that W is licensed pursuant to the provisions of the (Chapter
(commencing with Section 7000) a Division ] of IM Business and Pro c sinter Cade) or
17
that be Is exempt therefrom and the bub for the Alleged! exemption. Any violation of
APN Number
Occupancy Type
Section 7071.5 by say applicant for a permit subjects the applicut to a civil penalty of
not more than five hundred dollars (5500).
❑ 1, as owner of the prepeny. a my employees with wages as their able compensation.
20084.00 Required Inspections
will do the work. and the structure is not intended oroffered for age 7044, Business
had Profession, Code: The Contractor', License Law docs not apply to an oven of
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property who build, or im pima Ihetmn, and who dao such work hl mwl f w Ihmugh his
own employees, provided Ihalaueh Improvements am not Intended oroRercd foraak. If.
however. the building or Improvement Is wild within oro yew of completion. The owner
builder will have the burden of proving that he did not Wild or Improve for purpose of
sale.).
❑ 1. as owner of the propeny, am exclusively contracting with licensed mmrsetmrs Io
convect the project (See. 70th. Business and Pabfesnou Code:) The Contractor's U.
cense law does not imply to to owner of propeny who Wilds or Improve, theme, and.
who contracts for such projecte with a conlractor(a) licensed pursuant to IW ci nlraclors
License I.
❑ 1 um exempt under Seo. , B & P C for this rcuon
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby gi ine under penalty of perjury one of the following declarations:
ave and will maintain a CenlficAk of Consent to self -insure for Workers Compo -
union, ns provided for by Section 37M of the Labor Code, for the performance of the
work for which this permit is issued.
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❑ 1 have and will maintain Worker's Compensation Insurance. a inquired by Section
]7110 of the Labor Code, for Ne performance of the work for which this peon is issued.
My Workers Compensation Inabmnre artier and Policy number am:
Caller: /'I A.]�SiaiC W LPoliry No.: C.? OMo? S 3J
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
flab aecllon need nosh icomplemd if the remail is fmone Wndroddollars (SIM)
or Ian.)
I really that In the Performanre of the work for which this Permit is Issued, I shall not
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employ any Nixon in any towner sir as In become subject to lW Workers Campeamilim
Laws of California. Data
Applicant
NOTICE TO APPLICANT. If. after making this Certificate of Exemption, you should
Wow subject to the Workers Compensation provisions of the Ww Code, yen most
forthwith comply with such provisions or this Permit shall be deemed revalued.
CONSTRUCTION LENDING AGENCY
1 hemlry, &Man that them is a construction lending agency for be Performance of
the work for which this permit Is issued (Sec. 31191. CO. C.)
Under, Nene
Leaders Address
I I really that 1 ban read this application and sum that the shove Information B
conn. I agree to comply with all city and county ordinances nd ante bac relating to
Wilding construction, and hereby amhodw mpraentnhxs of this city to enter upon be
abovemenlianed property for Inspection purpsen
(We) agree to save, Indemnify and keep Wrmkss the City of Cupertino against
j liabilities judgment. Costs and expenses which may In any way scow against said City
In i
APPLICANT Eof the RSTANDSthisotaling of mit.
ANTUN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
Re -roofs
Type of Roof
incensey1/'aw.3.
Signature of AppllcanV Data
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future building=opwut= or handle hrurdon, material
as donned by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safety
ads, seclioe 2ss]2(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yeses
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the a04
pplicmt err fumrc building mcupem saw eyulpmem or desires which
hazardous air comandmi s as defined by the Bq Arca Air Quality Management
all new materials for inspection.
nmicl7
❑Yav
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I have mad the hasardommaterial, requirements under Chapter 6.95 of the Califnr.
nia Health &Safety Code, Sudan 25505,25537 and 25574.1 undersand that if the WIIding
data not currently have a tavern. that It is my responsibility to badly the aeupenl of Ne
mquiremenu which must be met prior m Issuance of a Certificate Of Occupwcy.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner in anther.. ge Data