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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITNO.04090217
OWNER'S NAME:
PERMR ISSUE DATE
12 9
SANITARYN P01901. NO,
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby affirm that 1 em licensed under provhiona M Chapter 9 (commencing
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with Section 7000) dDlvWon 3 of the Bminesaand Profe¢Inna Code, and my license ie
Or full tome and effect. B3 p 6 N /
Lice An Cl.. LM# 6 O b
NEW CONDO — 1368 SQ: FT.
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Dam Comncmr rSNd �a�
ARCHITECTS DECLARATION
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I understand my plant shall be taw puMi �—
Licensed PmfeWOnai
OWNEB. B 1 DE ECLARA7t0N
I hereby affirm that I am exempt from the Contrames License Law for the
Allowing Mama. (Section 703 1.5, Business and Professdoa Cole: Any city or county
which ox, lyes a permit to construct. Alta, improve. demolish, or repair any structure
prior In its Women, also requires the &ppbicam for such permit m file, statement
that he It licensed pursuant m the previsions ofthe Contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Secllon7000) of Division 3 orthe Busineaand Profusions Cede) or
that he Is exempt therefrom and the bash for the alleged exemption. Any violation of
Cl
APN Number
Occupancy Type
Section 7031.5 by any Afflicted for a permit subjects she Applicant to a civil penalty of
not mom than fin hundred dollen ($500).
❑ 1, a owner of the property. or my employees with wage u their sole compenssllon,
31620084.00 Required Inspections
will do the work, and the structure is not intended oroaered frsabe(Sao. 7014. Business
And ProfeWona Code: The Comminute, Lt.. law des not apply tu on ower of
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property who bu Ilds or improves thcrton, and who does such wosk hi mseI f or thmugh his
own employees. providd that such improvements art not Intended oroff ft! foals. if.
howeveA Ne building or Improvement is told within one year of compIdm. Ne ower
Iodide' will bun the burden of proving that ho did ret build or Improve for purpose of
ta)e.).
❑ 1, a ower of the property am exclusively conbadng wish licenced mntnemn to
construct the project (Sec. 70th. Business and profusions Code:) The Cmlractm'a Li.
cense Law dost not apply to an owner of property who builds or Improves Iherton. and
who contracts for such projects with aconuanorts) licensed pursuant to the Contnnots
License Law.
❑ lam exempt under Sec. ,B&PCfomhisauon
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby &fares under penalty of perjury aro of the following denclarmloa:
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and will maintain a Conifints of Covent m self -Insure for Worker's Compen-
aWm, u pmvlded for by Section 3700 of the Labor Code, for the performance of the
work for which this permit Is listed,
❑ I haw and will maintain Workees Compensation Insurance• u mqumed by Sedan
3700 of the Labor Code• ter the part... of the work for when this permit Is WwA.
My Workces Compensation Inwrauee Cartier and Policy number art:
Carier_Igi4%9mT•C r4-(' Policy No.:CAL�CLl'.5�3
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This aecdnn and not ism completed RIM Iermlt Is for mC hundred dollen ($101A
or Ion.)
I certify that In the psrtomaen of Ne work for which thin Permit is Issued. 1 shell not
employ anyperren in any manner an u to become subject m the Workers Compemadon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. Baer making this Certificate of Exemption. you should
become subject the Worker's Conepc utlon previsions of the Labor Code, you mum
forthwith comply with such provision or this permit shall he deemed rtwkcd.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a mm nximn lending agency forthe performance of
she woe for which this permit Is issued (Su. 3097• Civ. C.)
Isndafs Name
Undoes Add.
I unify that I lave read thl,spplication and mm that the show Information Is
1 &gra m comply with all city and county oo manus and me laws nlming m
building construction, and hereby&ushorine representatives of this city to enter upon the
shove-men0oned property forintr4don purposes.
(We) agree to ave, Indemnify and keep harmless the City of Cupertino against
liabilities, judgments, core and expenses which may in any way &come against said City
in consequence of the granting of this Farrell.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS—
EGULATION'C"'"
Re -roofs
Type of Roof
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Signature of Applin muamr Data
AZ S MATERIALS DISCLOSURE
Will the app's tar future building eceupant rom or handle haesNous material
As defined by the Cupertino Municipal Code. Chapter 9.12, and The Health and Safety
Cnaa,Secdm 25532d?y
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building Occupant use equipment or devices which
tarardms air cmtsmbmants u dcOncd by the Bay Ara Air OnAdry Management
all new materials for inspection.
District?
❑Yea �
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1 have real the havandmwsmaedals requirements under Chaper6.95 orthc Califor-
nia HcAm&Safely Cade, Secdaa25505,25533 md25534.1 understand the0fthc Wilding
does not currently haw a ream, that 11 Is my retpnmiblltty to nudity the eeupant or Ne
mquiromcnh which must be at poor m Issuance or a Certificate of Occupancy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner or authorhad Data
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