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BUILDING DIVISION PERMIT`CC1N'T.1kCTi7R
IN"pA"CYON•'°
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.
04090214
OWNER'S NAME:
PERMITISUEDATB
e:
SANITARY N . L NO.
ARCHITEC IE IGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB KAREN
I1 0
LICENSED CONIRACTIDR'S DECLARATION
Job Description
1 baeby in. Nn 1 am Boomed under provisions of crisper 9 (commoncing
with Section 701311) of Division Jof W Businw and Profepims Code, anal mY license is
in full force and tffect.
License oo
Lk.N RIM
NEW CONDO - 1530 SQ-. FT.
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Delo cmaracm��ALf.tA�
RCHITECPS DECLARATION N
I understand my plans he used as puh
Licensed Professional
SOWN RDECe
ConumON
1 hereby affirm that I m exempt from the CamnmaM1 License Lew for the
following mason. (section 713 L5, Business and Professions Code: Any city or county
which mqulres a permit to construct, alter. Improve. demolish, or repair any structure
prior m its issuance, also requires the applicant for such permit to rile a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the ContractoM1 License Law (Chapter 9
(commencing With Section 70113) of Division 3 of the Business and Profession. Code) of
Nat he is OUMPI daorefmm and da, bub for the alleged exemption, Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to A civil penalty of
not marc Nen five hundred dollars (3500).
❑ I, As owner of the progeny, Or my employees with wages Am their sale compensation,
31620084.00 Required Inspections
will do rite work, and the ahacmm is not intended or offered for eale(Sm. 7041, Business
and Professions Cade: The Common's License law does not Apply m an owner Of
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property who builds or Impmv thereon, aM wha doessuch work himself or through his
own employees. provided Nat such Improvements arc not Intended m offered for We. If.
however, the Wilding or improvement Is mid within am year of completion. dae owner.
builder WHI haus the burden of moving Nat be did not Wild or improve for purpose of
ole.).
❑ 1, as owner of the Property, am exclusively contracting with licensed cenummn ro
consumer the project (Sec. 705, Business and Professiom Code:)The ConuacmYs I.I.
cave Law does not apply to an owner of property who Wilda or improv daemon. and,
who cmuacts for such projects with a conoasmr(O licensed pursuant o the Conuanoes
License Law.
❑ I am epopl under See ,B da P C far this moron
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following dmlaratiov:
1 have and will melnbin a Cenificam of Consent 10 self-ivum far WmtetaCompen-
aalion, As provided for by Section 37M of the labor Code, for the performmm of the
work for which this permit b issued.
❑ 1 have and will maintain Worker's Compensation Insurance, As required by Section
37M of the Labor Code, for dae performance of the wank fm which this permit is hmmd.
My Workees Compensation Insunnce carrier and Polley number Art:
Carrier: MAJ<D%a C Policy Na.: e.QL10sAr7533O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Obb section need not W completed if the pefmit Is (mune hundred dollars (5101)
or leas.)
1 cenify Nat In the poformanee of the work for which this permit is issmd, I shell not
employ any Person In any manner in As to become subject to the Worlcre Compensation
Law. of California. Dale
Applicant
NOTICE TO APPLICANT: It, After making this Certificate of Emmption, you should
become object m the Worker's Compensation provisions of the tabor Code, you must
forthwith comply with such provisions m this permit shall M domed revoked.
CONSTRUCTION LENDING AGENCY
I hereby sfllrm that there Is construction lending agency for the performers¢ of
the work fur which this permlt is ipucd (Sec. 3097, Civ. C.)
Name
I<nder's Addmu
I cenify that I have mad this Applicatiw AM sat¢ that On abuve information is
I agree to comply with III City aM county On insnces And.lats laws mining in
building conwuction, and hereby authode, mPmn,rumom of this city in enter upnn the
abovementim¢d property fm inspection Pugmsea
(We) agree to part. IMemnifY and keep harmless the City of Cupenino against
liabilities,judgments, cum most expenses which may in my way amus against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTAND, AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
/" 57
Re -roofs
Type of Roof
Signature of APPIinnVCOnuact Data
HAZARDOUS MATERIALS DISCLOSURE
WIII Lha applicant at future Wilding occupant stare or handle harsNous material
As defined by the Cupertino Municipal Code, Chapter 9.17, and the Health and Safety
Code, Serta. 75537(.)7
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All roofs shall be inspected prior to any roofing material being installed.
If a roof Is installed without first obtaining an inspection, I agree to remove
I❑Yes/r futoTO
Will the applicant obuilding Occupant use equipment or devices which
t heesrdous air contaminants a defined by the Bay Area All Quality Management
all new materials for inspection.
DleviclT
❑yea
I have mW the harardnus materials n quimments under Chapter 6.95 of the Califor.
nia Health A Safety Cade, Sections 25515.75533 and 75339.1 understand that RIM building
does not currently hem a Mount, that It Is my responsibility in notify IM Occupant of rite
regmmments which must be met Or to b.uance of a CaNOcaw of Occupmoy,
Signature Of Applicant Date
t
tre'o
All roof coverings to be Class "B" or better
Owner ur uth.,iredaenl not