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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090203
OWNER' AM :PEVR?iSGRK
PERM1TISRIEDATS
SANITARY & iftOL NO.
ARCHITECVENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm that 1 am licensed under pmvisimrs of Chapter 9 (Commencing
with Section 701D) of Division J of the. Beat. and Profession, Cade, and my license to
in tun force and effect. �j'3-!d' OV iv
Llcena Cl L Lk.g
NEW CONDO -1087 SQ. FT.
Data `s-� h e s.r�['amn"a rim
—
HITECrS DECLARATION
I understand my plans ha du a Curti
Licensed Pn,feumnal
OWNERZUERDECLARATION
I hcrchy in. Thal I am exempt from the L'Onlrsmar', License Law for the
,
following .on. (Section 7031.5, Blues, end Profusion, Code: Any city 01 County
which requires a permit to Construct. alter, improve, demolish, or mpair any structure
prior to its Issuance, also requires be applicant for such permit to file ulgned ststemcnt
ConuacwiaUcenw Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that Mi. licensed pursu.m to the previsions of the
(commencing with Section 7010) of Division J of the Business and Profcrtion, Code) m
.on
Nu M la exempt themfrom and the basis for the alleged exemption. Any Wotan of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit ubjects the SpplicWL to a civil penalty of
not mon than five hundred dollars (SSW).
❑ I, asmvnuofthoproperty, or myemplayeu with wgu Astheir sok tompenution,
3 16 2 0 0 84 . 0 0 Required Inspections
will do the wart, and thesuucmm is malmended oroffOrd for sale (Sec. 7014. Basis.
and Profnrcons Cont: The Comnctor'a Llcena Law does not apply to an owner of
property who builds or Improve. thereon, and who dec,.uch work himself err through his
Own employers, provided that such improvemenu tee not Intended or offered for sale. If,
however, the building or Improvement Is mid within one year of completion. the owner.
.
builder will have the burden of proving that he did not build or Improve for purpose of
Asia.).
❑ I, as owmur of the proper• am nelusivOy contracting with licensed contractor, m
construct the project (Sec. 7014, Business and Professions Code:) The Comment's U.
cense law does not pply to an owner of Property who builds or barroom daemon, and ,
who contracts for such projects with a contractor(s) licensed pursuant to the Corrientes
License Lew.
1 am camp, under Sac . B & P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby efares under Family of perjury one of the fallowing declarations:
...ad will maintain • CudiOum of Conant to rtlFlnsum forWmYer'. Compen-
Astian, As provided for by Session 3700 of the labor Code. for Dae performance of the
work for which this pcmdt is issued.
-
❑ 1 have and will maintain Wmkeez Compensation Insmace, as required by Section
3701 of Ne Labor Code. far the Performance of the work for which this permit Is loved.
My Worker's Compensation Insurance carrier and Policy number art:
Carie,'. 14AJt5i rC SVC Policy No,; 4200gbZ1930.
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thi.,eednn Cast not mcompleted If the permit la for one hundred dollm(SI00)
or kat.)
1 Certify that in the performance of the work for which this permit is Issued, l .hall not
employ any person in any manrwr an as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. If, after making this Ce tiftnu of Exemption, you should
become ,object to the Wohu'. Compensation provisions of the Lab, Code. you must
forthwith comply with such provisions or this permit hall be decreed revoked.
CONSTRUCTION LENDING AGENCY
1 herebyAllenNat then Is s lending agency for the Performance of
ed (Sec. 30
tin, wash for whim this permit is lured (Sec. 3(197, Civ. C.)
Lender'sName
'
Addrcu
LenAdd.
I Certify that 1 have rad this application And rete dust the W. Information is
COMM. 1 agree ID comply with All city and county ordinances nd rete laws relating do
Wilding convection, and hereby amhnd. apnunla0.s of this city 10 enter uPnn the
1 above-mentioned properly for Inspection purposes.
(We) agree to save, indemnify And keit harmleu the City of Cupertino against
j liabilities, judgments. costs and expenses which may In any my ACCM against said City
In conequence of the Starting of I APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULAT
Re -roofs
Type of Roof
y'z/ e�
Signature of ApplicaV Due,
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant no future building e,cupanumrc or handle material
Health a
as Maned by time Cupertino Municipal Code, Chapter 9.12. and time Health and Safety
Cnm,Scedon 25532()7
All roofs shall be inspected prior to any roofing material being installed.
❑Ye. No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future �kdlrql Occupant use equipment or dcvIceA which
h and oo, akanumin,nu u arced by dte Bay Arta All Quality Management
all new materials for inspection.
❑ Yc,
I hive aatl the u&m materials onubemenu under Chapter 6.95 of lisp Carol.
Id-,
eal" Safeq Cade, Sections 25505,23533 and 25534,1 understand tout lfft Wilding
not Carmody have, a nem, that it k my remomiMllly us notify the nceuPat of Nu
lremenuwhich�anALJcmelpdormluuencoo(.CcniacamofOcupacy.
4/
Signature of Applicant Date
�
All roof coverings to be Class "B" or better
m or anthoriyn!! agent Date