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CITY OF CUPERTINO
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BUILDING DIVISION PEST
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T1 'O ATbIONc-,
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N904090206
OWNRR'S NAME:
PERMIT ISSUE DATE
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SANITARY 0. CONTROLNO.
ARCHITECT/ENGINEER;
BUILDING PERMIT INFO
BLDG ELECT PLUMB Mn
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I Mmby affirm that I am licensed under provisions of Chapter 9 (commencing
P
wkh S.sion 7M)).f Division 30(ft Business and Professiu Cade. and my license is
in fall fnceandeffect. J6 g3$OH6
NEW CONDO - 1087 SQ FT
Dam Lr —] PA SM/�
Do. Clans Congo
ARCHITECTS
ARCIi1TECTS DECLARATION
"
I understand my plan s be es d u otic rtcnr ..
Licensed Professional
OWNER.BUILIIER DECLARATION
I hereby affirm that I am exempt from the ContmOor" License IAw for the
following mature. (Section NO 1.5. Business and Professions Cade: Any city or county
which requires a pereft to cementer. almr, improve, demalah, m repair any manctum
prior In its issuance, Also require, the applicant for such permit a file asigned nommen
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to IN prevision of the Common', License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profession, Code) or
that he Is exempt therefrom ad the bus far the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant fora permit subjects the applldanl In & civil penalty of
not mom dun five hundred dolan (9500).
0 I.ur ofthepropeny.omyemployeewithcagesa Neomle=pcmti n,
084.00 Required Inspections
wllldo IN work. and theswc,u,a not intended oa(fcred forsake (Sec. 7044. Business
rs Llcee Law does rot apply N ,n owner of
and Profession Cade: The CanuamM
q P
property who Wilds or Improve, thereon. and whodoeuoh work himselfar through his
own employ.., provided that such Improvements we not Intended ooRered for ale. IL
however, We building or Improvement Is sold within one year of completion, Ne owner.
hullder will have ,he burden of pouring ban he did not Wild or Improve for purpose of
sale.).
❑ 1, as owoer of the prepeny, am exclusively conhsedng with licensed conuanan to
construct the pmjen (Sec. 7044, Business and Profusion. Code) The Contractors U.
.oar Law does not apply to an owner of property who WIIM or Improv rhemon, and
who contracts for Such projects with a contractor(,) licensed pursuant to the Contractee"
License Law.
❑ I am enmpt under See. , B A, P C for this moon
Owner Doh
WORKER'S COMPENSATION DECLARATION
I hereby aalrm under penalty of perjury am of the following daarsdou:
ave and will maintain • Cerdfica a ofConsent to self.idnum for Workers Compere
orlon, u provided for by Section 3700 of IN IAWr Code, for the performance of the
work for which this pearl, is ineud.
❑ I have and will maintain Woker's Compa&Ilro Iuunn., as required by Section
3700 of Ne Lshor Code. for the performance of Use work for which this permit is Issued.
My Workers Compensation Immance caner and Policy number art:
Canter. 47d&#S n^_ Policy
EXI FROM WORKERS'
RTiCjPI70N
'
COMPENSATION INSURANCE
Qhs session need not be completed lithe Permit Is form= hundred dollars (SIM)
or less.)
I sonify that In the performance of the work for which this permit is issued, l shall net
employ anypenon in any manner m u m become object m the Workers' Compensation
Law, of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Crnifinte of Exemption, you should
become subject N rhe Worker's Compensation pmviaiao of IN IAM Code. YOU rower
forthwith Comply with such provisions or this permh shall he deemed mroked.
CONSTRUCTION LENDING AGENCY
I hereby affirm Net loam is It coruwcdnn lending agency for the Performance of
the work for which this permit is issued (S.. 3097, Civ. C.)
LeMera Name
Lender's Address
I Certify that I have read this application and nam that, IN above Infmmnlem is
correct. I mace, an comply with all city and county ordinance, and sato law, nelning In
Wilding cootmcdon, and hereby autharia mpmsentatives of this city to enter upon the
above-mentioned pmpeny for inspection porpoies.
(We) .gree to eve, indemnify and keep harmless the City of Cupertino against
liabilities, Judgments, coo and expenses which may In any way sceme agsinnsaid City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type
Signeure O(Applicaat Comracto Data
HAZARDOUS MATERIALS DISCLOSURE
of Roof
Will Use applicant or future building Occupant same or handle ooArdous material
u defined by the Cupenino Municipal. Code. Chapter 9.12, and the Health and Safety
Code, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yes \
/
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant lata equipment or device, which
hsyardous m, contaminant, as dcfincd by IN Bay Area Air Quality Maugement
all new materials for inspection.
Bict7
❑Yes
I have mW the haard.s materials mquimmena under Chap er6.95 of the Ciifor.
nla Hcal" Safc,y Cade, Swdou25505,25533 and 25534.1 undersua d Iheifthc Wilding
dues not Carmody have a mnmL that it is my responsibility in rodl'y the occupant of the
requirements which must be met pint to issuance our a Certificate of Occupancy.
Signature Of Applicant Date
°
All roof coverings to be Class IB" or better
Owner onmhomcd a emm Date