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CITY OF CUPERTINO
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�CONTR,CTOR I„„Nd�FO MATION
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT
4090205
SMIXOIA91TVENSPERMIT
ISSUE DATE
ARTNERS
E;IDERTfNO HOUSING PJ
969 Abl"Ift STREET
1,650-1179 47OG
SANITAR CONTROL NO.
ARCHITECr/ENGINEER:
BUILDING PERMIT INFO
BLDD ELECT PLO
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
o P
I hemby afwm dui 1 Am licensed under provlal"s of Chapwr 9 (commencing
with Section70010of Divitfon3ofthe Budnw RofeWum Codo.andmylicenseh
b fnE forte and./reek k
ucena etas. B sea.$
NEW CONDO -1087 SQ. FT.
Deb 4 Contracts,
ARCHITECTS OF.CLARATION
1 undcmenJ myyl;ps abet and a rtcnrW
LicAP,d Pmfns&iunel •T "' f
OWNER -BUILDER DECLARATION
I hereby affirm Net I em exempt from the Cnmrenoe, License Lew for the
following reason. (Section 703I,3, Business and Profeaslnns Code: Any City or county
which requires a Form, to construct, elms Improve, demolish, or repair any nmmum
Prior to its issuance. him requires IM applicant fonuch Permit o rile asigned statement
de Common's U.P. Law(ChAFler 9
Sq. Ft. Floor Area
Valuation
that he is licensed puiwant to the provieinnsof
(commencing with Section TODD) of Division 3 of the Business and Profcasinna Co P)or
2 5 8 31
and de ole for de Alleged exemption. Any v10alfon of
exempt efrom b
Mat he u thm
APN Number
Occupancy Type
Section 7031.3 by any applicant for a Cammiuubjects Ne applicant 10 A civil penalty of
not more Nen five hundred dollen ($300).
0 I, u owner of the property, or my employ”, with voiles as delr vele eamp",artm.
3162008400 Required Inspections
will d0 the wart, and Neswclum B not intended ar offered for W. (Sec. 7041, Business
and Professions Code: The Commerce, License Law does not apply b an owner of
. 9 P
propeny who build, or Improves Neuron, end who d"uuch work himself or through his
Own employcea, provided Nat such Improvements are not Intended oroffernd foreek, IL
however, dm building or improvement is old within one year of completion. Ne owner.
builder will ha" Ne burden of proving that he did not build or Improve for purpose or
Able.).
❑ L as owner Of de property am eanlumvely conuacling widd licensed contractors to
connrvcl the pmjem (Sec. 7044. Business and Professions Code:) The ConnowwrY Lw -
Co. law does nod Apply ut an ow"r of prawn who builds a, improv Neuron, and
who comncu fm each produces with o toms cu,(s) licensed pursue, In ft Conuonor's
License law.
❑ I ort exempt under Sec. . B A P C fm thw, m mss
Owner Dale
WORKER'S COMPENSATION DECLARATION
1 hereby &from under penalty of perjury one of the following declarations:
ave and will maintain a CeniOcae of Commut, ro self-Insua for Worlmr's Compen.
m on, a provided for by Section 3700 of the Labor Code, for the perimmance of the
work for which this permit Is issued.
❑ 1 hove and will maintain Wallace, Compensation Insurance, a required by Section
37M of Nc labor Code, for the performance of the work for which Nie permit Is Issued.
My Work e. Cmn,m.0.n In.= candor and Polity number art:
center: Ia010-s7:C Policy N.,
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section reed notbecompleted If Ile Permit is for one hundred dollan(SIM)
Mle,e.)
1 cenify that In the performance of No work for which this permit 1, Issued, I shall not
employ any person in any mm"r an a an become robject to the Workan' Compeinatinn
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this Cenif¢am of Exemption, you should
become subject to the Worsens Compensation pmvLion, of the Labor Code, you must
forthwith Comply with such provision, or this remit Alnll be deemed revoked.
CONSTRUCTION
agency for Ne performance of
cdon tending agency
1herby affirm that demhoed(S.,
.0 h,
Ne work for which NB permit is issued (S". W. Clv. C.)
Landcr'e Name
leneerl Adam„
I cenify Net I have reed this application and mlo that the above Informellon is
correct. l agree to Comply with all city and county ordinances and lute laws renting to
building congmnion, and hereby AuNurhe mpma iatwes of this city to color upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j IwabllwOeL judgments, core And expense, which may in my wry same against said City
In APPLICANTCUNDERSTANDS Aof the suenting of IND WALL COMPLY WITH ALL NON -POINT
Issued by:91taraaa Date
SOURCE REGULATIONS.
Type of Roof
-'c"--Re-roofs
Signature ol'ApplIcalleaCommeVmA
HAZARDOUS MATERIALS DISCLOSURE
Will tie applicant or future building Occupant wre or handle hawdou, mamdal
As dented by the Cupenino Municipal Cade, Chapter 9.12. and the Health end Safely
Code. Seeks 2353z(a)T
All roofs shall be inspected prior to any roofing material being installed.
I-] Yes
If a roof IS installed without first obtaining an inspection, I agree to remove
Will the applicant or rowan ba Iding occupant use equipment or devices which
hamodnos air contaminants An dented by the Bay Ama Air Quality Management
all new materials for inspection.
vier
❑ Yus
I have mad The hasiN"s malonel, mquirem"is under Chapter 6.95 of the Califon
nu Health 8 Safety Code, Sections 75505.25533 and 25534.1 um crNM dus lfthe Wilding
doe, trot currently hoe • mnank Net it is my reer manhlllly b rodfy de aaoupant of Ne
mgmmmenuwhich mum tan mnprior w issuance araccnrmamofoecaranm.
gnatureofApplicant Date
- H 4/ °-
All roof coverings to be Class "B" or better
Owner or aulharwmd qen Dam
15L