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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090204
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY N L NO.
ARCHITECUENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTORS DECLARATION
Job Description
I hereby sf Ion Ilut 1 am licensed under provisions of Chapter 9 (commencing
with Section 7001) of Division 3 of the Business and Potassium Cade, and my license is
In full forte and effect.
License Class LIc.M RBRBti(,a
NEW CONDO -1087 SQ. FT.
- -
Dau Comrumr PNLPCMtl
AR Hf1ECrS DECLARATION
I understand my plana:hall u d u public records
Licensed Professional
OWNER-BUI DECLARATION
I hereby affirm that I am exempt from the Contractors Lecture re Law for the
following moon. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to consume[. alter, improv, demolish, or repair any structure
prior to las Issuance, also requires the applicant for such Permit to file a Signed statement
ase Contractor's Law Whapler 9
Sq. Ft. Floor Area
Valuation
that he is licensed Puruanl to the Provision of cense
(commencing with Section 70DO) of Division 3 of the Business and Profminas Code) or
Nat he Is cumin tW.efrom and the, huts for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a Permit the applicant to a civil Penalty of
not mart Nu love hundred dollars (1500[.
❑ I, as want ofthe property, or my employees with "Sea in their sole compensation,
31620084.00 Required Inspections
ns
will do the work, and the s.uctuha is nothumded molfertd for isle (Sec. 704/, Business
and Profeselaas Code: The Chanteuse, License Law dean net apply as as :vena of
9 P
properly who builds or Im prove+ thereon. and who does atilt work hlmxelf or through his
ownemployees. provided thatstch improvements ase no tsmanded or offered (mule. If.
h..,, Ne Wilding ar improvement Is .14 within oro Sear of eomplWon, the owncr-
Wilder will ban the Wrden of proving that he did nut Wild m Improve far purpose of
sale.).
❑ 1, as owner of Me property, am exclusively contracting with licensed contractors to
construct the project (Sec. 7004, Business and Professions Code:) This Con ostwo's Lb
cense law docs not apply to an owner of property who Wilda or Improve thereon. and
who contracts for inch pabmcw with a commuter(s) licensed pursuant to Ne ContrxemM1
License law.
❑ I am exempt under Sec. . B & P C for this reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby &Man under Penalty or perjury one of the following declvniou:
W Croatian-
1ksw and will malnn a Certificate of Consent to self -num for Workers Compen-
utian, . provided for by Section 37M of the Labor Code, fan the polmou race of doe
work for which this permit Is issued.
'
❑ 1 haw and will maintain Workers Compensation Insurance, in required by Section
37M of On labor Code, far oho performance of the work for which this permit I$ ianued,
My Workers Compensation Insurance carrier and Policy number am:
Cartier. lk,.G Policy No.: a 330
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section .0 not W compuud If Ibe Permit is sone WmindIdoliat (SIM)
.r Wee)
I certify that in the performmco of IW work for which this Permit is Issued, I shall not
employ anyperun in any manner an in 10 become Subject to lW WorkeW Compensation
Law, of California. Dau
Applicant
NOTICE TO APPLICANT. If. afar making his Cc tificau or Facmption, you should
become subject to an WMIme. Compensation provisions of the talar. Code, you muse
forthwith comply with such provisions or this Permit shall be deemed hawked.
CONSTRUCTION LENDING AGENCY
I hereby aMo. that there las construction landing agenry far the perfmman r of
Me work for which this permit Is iuved (Sec. 3097, Ch, C.)
Landers Name
UndeM1Address
I certify that I have rod thla application and sou that the above information Is
cortecl. I as= to comply with all city and county ordinances and State laws relating to
building construction, and hereby sumorlm representatives of tai, city to tour upon the
above-mentioned property for Inspection purposes.
(We) agree to an. indemnify and keep harrower the City of Cupertino against
j liabilities, judgments, costs and expenses which may In any my seem against said City
In conence of the i APPLIC NT UNDERSTAnunthNDS ANof thisD WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
--2 t-
Signature of AppllcanVCOmnct Onto
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or futon building occupant sham or handle Imandous material
u defined by the Cupertino Municipal Code. Chapter 9.12. and the Health and Safety
Code, Section 25532(x)71/
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future Wilding Occupant use equipment or dcvlms which
hoard... air m umni.ams as defined by the Bay Area Air Quality Management
all new materials for inspection.
let? p
❑Yea
I have read the hmAndous materials uquiromem, underCMpur6.95 ortiu Califor.
nia Neellh& SafctirCOde. Sectimts25505.23333 and 25534.1 undca mnd this ifdm Wilding
dors rut curtenlly haw a umnt. that II Is my ha,POMMOILY to rmdfy the accup ct or the
requimmanu which on W met prior to is h.ra CcrdRcamaroccapancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or aunhorlrcdapt ol Dm/
ai
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