04090212D. P
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CITY OF CUPERTINO
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BUILDING DIVISION . PERMITpLg�Q-RINFURMA'.x,
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090212
R Agp
PERMIT ISSUE DATE
�T PRTINQ RG^TUTSING ;P.R1
SANITARY OL NO.
ARCHITEC 7ENGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MUCH
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LICENSED CONTRACTOR'S DECLARATION
]b Description
under provisions of Chapter 9 (commencing
1 Mrcby affirm MI I am IbecomesO
P
With Section 70111) of Division 3 of rho Bestow and professu... Code. and my Iicenxe is
In full farce and effect.
Llceme Cla& Le.M A.3RD�f6
AWL.
NEW CONDO - 1131 SQ.' FT.
Dam b Conlncb bal-L�
ARCHITECTS DECLARATION
1 undcnssnd my phru epW{wysetl o public rteuM
Licensed Professional - _
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for the
following moon (Section 71131.5, Busies& and Professions Code: Any city Of county
Which requires, • permit m ennsuucL atter. Improve, demallsb. at repair my nrmflue
poor in its Iau.nce, elan acquires the applicant for such Permit to rite a signed statement
Sq. Ft. Floor Area
Valuation
that he is lim sed pursuan0o the provlsmasof the Contractor's License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
that he Is exempt therefrom and the bull for the alleged assumption. Any violation of
APN Number
Occupancy Type
Section
e mom1013imnveh�applicantf s5penniisubjectsthe applmmnoacivil penalty of
❑ 1. As Calow of the property, or my employees with wage u their sole comp reatlon,
3162008400 Required Inspections
will de, the work,md the structure Is not amended ar offered fonae(Me. 7044. Business
Law donot apply m an Commownm of
and Profession Code: The Contraemr's Llceaae e
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propenywha builds or improws thereon. and whodoes such Work himadfarthrough his
ownemployces, provided Nu such improvements us not intended oro@red rorsale. IL
however, the building or Improvement is sold within ane you of completion, the owucr-
builder will have the burden or proving that he did not build or Improve for purpose of
sale.).
❑ 1, as moor of the property. am exclusively contracting with IImaW canummers to
convect the project (Sec. 7044. Business and Profession Cade:) The Con racmM1 Lb
ceae law doe not apply to an owner of property who builds or improws theater, and,
who contracts for such projects with a contractor(&) licensed pursuant to the Contractors
License Law.
❑ 1 am exempt under See. . B h P C for this mason
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby &Man under penalty of perjury ON of the following declaration
1 haw end WIII mal ild.a Certificate of Conant to sel6laum for Worker's Compete
salon, As provided for by Section 3700 of the Labor Code, for dm performance of the
wart for which this permit I. ivued.
❑ 1 haw and will maintain Worker's Compensation Insurance, As required by Section
3700 of the Labor Code. for the performance of due work for which this permit is Issued.
My WodeYs Compensation Inannnce carrier and Policy number are:
Carrier. �La..Q'a�~ Tr'(/ Policy No.: _C
��
RTIFICA�MON PROM WORKERS'
COMPENSATION INSURANCE
(Thlsseetion reed not wcompleted If the Permit Is for one hundred dollars ($100)
carless)
I certify that in the performance of the work for which this Permit is isamd, I Nall NO
employ any Person in any manner an u to become subject to IN WarkCre' CumP MMIN
Laws of California. Dole
Applkanl
NOTICE TO APPLICANT If, afar making this Certificate of Exemption, you should
became subjat m the Worku s Compensation Provisions of the Labor Code, you most
fonowith Comply with tech provisions or this Permluhall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alarm that them is a construction lending agency far die performam<of
Ne Work for which this permit Is loved (Sec. 30017, Civ. C.)
Lender's Name
Lender's Address
1 sonify that I haw read ibis application ad &sate that the above Information le
carbon. I agree to comply with all city and coumy ordinances nd stste laws mining m
building construction. and hereby mthoom bopresantstiws of talk city to enter upon the
above-memmoed property for hammed. perp mes.
(We) agate to sew, Indemnify and keep burden the City of CUPWIno against
liabilities.judgments, eats and expenses which may In my wry mcnam against old City
In consequence of the Starting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
xv
Sigrumme.fApplicarvcTrusm. Date
MXMIALSDISCLOSURE
HAZARDOUS
Will the applicant or future building occupant mom or handle hax"oua material
as defined by the Cupenlno Municipal Code. Chapter 9.12, and the Health and Safety
Code, Seddon 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
QYek No
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the epplicentor future bat dingacupant uucyulpmcnlorJcvim& which
t huudaa ole contaminants u darned by the Bay Arca Air Quality Mansgemeal
all new materials for inspection.
District?
CYa�\
I haw mad he harsrdous materials requirements under Chapter G93 of the Califor.
nia Hal” SafetyCNk% Sections 25505.25533 and 35534.1 un lmemad that If ue building
docs not currently haw a rental, that It is my ruP rombility m trusty be occupant of the
requirements which must N met prior at Issuance of a Cenifea, of occupancy.
Signature Of Applicant Date
Lf.EL
All roof coverings to be Class "B" or better
Owner ser suhmixed a ant Date