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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
"PRIM, >.T3MATI0
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO, 04090210,
OWNER'S NAME:
PERMIT ISSUE DATE
'10
E:
SANITARY N9. OL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
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with Section 70110).f Division Sof No Business and Professions Cade, and my license is
in full farce and effect. R3R �G
Licenw Clans Lk.g
NEW CONDO - 1131 SQ'. FT.
Due /A .Se/d -,C_
ARCHITECTSDECLARATION
TSDECLARATION
1 understand my It... chat d upuhlic rtes
/J
Licensed Poor ..i.e.[
OWNER -BUILD DECLARATION
I hereby effort that I am exempt from the Contractors License Law for the
fallowing moble. Section 7031,5, Business and PlafeflelON Lode: Any city Or county
which requires a permit m construct, Alan Improve, demolish, or repair any Structure
prior w its Issuance, also requirenho mplicam fonuch permit m Ole s signed Statement
Sq. Ft. Floor Area
Valuation
that he is licensed punuam to the provision of the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
That k is exempt therefrom and the bum for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit ubjects the applicant to. civil penally of
not lame than Ove hundred dollar. (6500).
❑ I. as owner afthe property, or my employees with wages an their win compensation,
31620084. 00 Required Inspections
will do the wade cod dewucmr is nountendedornfferd for aale,(Sec. 701x. Business
and Profevians Code: The Conuacron Lleame Isco does not apply ur an owner of
9 P
property who bui ldi or Improves Theorem. a Std who doessuch work himeelf or through his
own employes, provided Nu such Improvements ace not intended oroffered (mule. IL
howewr. des building or Improvement Is acid within one year of completion. the ewar-
builder. will Nes the burden of p .vl.g Na he did not build m improve for pulpa of
ole.).
❑ 1, as owner of rip property am exclusively contracting with Ilceaed mmraemrs to
construct Ile project (Sec. 70,14. Business and ProfeWoes Code:) M Conuwur's U. -
cense Law dao nm apply to an owner of property who builds or improves thereon. and
who contracts for such Projects with a contraloms) licensed pursuant an the conircmn
License Law.
❑ I am exempt under Sec. . B & P C for this lesson
Owner cars
WORKER'S COMPENSATION DECLARATION
I hereby aRmnt under penury of perjury one of the fallowing declarallons:
I ham and will malmain a CenlOnte of Consent to self-inwm fm Worker's Court
nation, a provided for by Section 3700 or the Labor Code, for the performance of the
'
work for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Insurance, as required by Section
37W of the Ube, Code, for the performance of the work for which this permit is issued
My Workk,oLr.'s Cnmpenution Insurance carrier and Policy am:
•number
Carder: r=g q�%9i.7C 1'a4C PoRry No{3-�
CERTIFICATE OF EXEMPTION FROM WORKS S'
'
COMPENSATION INSURANCE
(The& secl Ion need not he comple ad I Dk Permit Is for one hundred dollar (S 100)
or ins.)
1 unify that In the performance of The work for which this Permit is issued. I shall not
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employ any person in any manmr w as an become subject to the Workeric Compensation
U. of Caiffomla. Dap
Applicant
NOTICE TO APPLICANT: If. afam making thin Cer ifcau, of Exemption, you should
become Subject in the Workers Compensation provisions of one LaWr Code, you moa
forthwith comply, with such provisions a Nis Permit shell k deemed rtwked.
CONSTRUCTION LENDING AGENCY
1 hcmby effrrm cast Ther is construction lending agency for the performance of
the work for which this permit is issued (Sm. 3097, Co. C.)
Lenders Name
Lenders Addma
I certify thus 1 hew mad cam application and nate that cat stow Information is
correct. I Ira m comply with all city and county ominames cod nate laws sluing 10
Wilding construction, and hereby authodm represematim of this city to tear upon the
above-memioned property for Inspection proposal.
(We) agree to save, indemnify and keep hamlets Ile City of Cupertino against
Ilabllilim,judgmonu,cuusndeapenwa which may In coy way same against mid City
In conaequemc of the granting a( this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Type Of Roof
Signature of Applican Dam
HAZARDOUS MATERIALS DISCLOSURE
Will line applicant or failure Wilding occupant amp or handle ham lous materia
as defined by the Cupanlno Municipal Code. Chapter 9. 12. and the Health cod Safely
cwt,smYin Section 25532(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Y(d Nu
a roof is installed without firs[ obtaining an inspection, I agree to remove
II, Will the applicant or future Wilding occupant uwmulpmem ordeviceswhich
luIf
, havudmis all mmaminanu as defined by the Bay Area Air Quaiby Management
all new materials for inspection.
District?
❑Yea DrNo
I have MW the thoardmsmaterials requirements under Chapter 6.95 of the Celifor-
niaHui" SmctyCom. Smtiou 75515,35533 acre 2553/. l understsnd thus ifthe Wilding
doss not curmmiy hew a anw4 that It u my supommility in notify the occupant of An
requirments which muss el poor or issuance of a Cndfinte of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner m amhml ad a Date