04090183CITY OF CUPERTINO_777171
BUILDING DIVISION PERMIT
(?N' "�' 0 INF'U'CtMA.r[bY0%
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO. 04090183
OWNER'S NAME:
PERMrr ISSUEDATB
E:
(rSqQ)470- 700
SANITARY NO. CONTROL NO,
ARCHIIECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Thal l me licensed under provisions of Chapter 9 (commencing
with section 7").f Division 3 of the But .and Profession. Code, end my It,,. is
tnfullf rreindeffCct. B S.3gOk �r;o
NEW CONDO -1589 SQ FT
LkenO Cl�ja . Lk. g
Dei �r� f O A� Conirscbr 'L
ARCHITECT'S DECLARATION
I understand my plans shell u as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm 4w for the
1 am eseropl from the Cnnmnat
CoLicense:c
following women, on 7031.5. sineasand POfeWnNCode; Anyean mcoumy
wome
t construct, Improve. h ri repair
which nqulm permh In
permit
ed omemum
Permit t.
es;theatkt
n anngn the IW applicant for such Permit to OleseLaw Ntemanl
pdme+stcensed pursuant
llcenidPunusnumheofDProvision,
Sq. FL Floor Area
Valuation
sion3theComrOessammnOlaw(ChapterY
(commencing with Section 7000) of Division 3 of Tho Business and ProCode) or
(comma
$183942
empl thentin rrom and bub for Ne alleged exempllon. Any Any vl violNon of
Net he uae
APN Number
Occupancy Type
Section 7031.5 by any applicant fon permit subject the applicant to s civil penalty of
not mon than five hundred dollars (5500).
❑ 1, u owner of the property, or my employees with wages he their sok compensation,
'
aired Inspections
will do the work, and the swnu.1. am ininded or offend for this (See. 7011, BusinessRe
and Professions Code: The Conuscmr's License Law time not apply i an owner of
q P
property whobulldanrimprovea themen.end whodnenuch work hlmselfor through his
-
own employers, provided that such Improvement are not Intended unfenced for sale. If.
however, the hullding or Improvement Is Old within one year of completion, the owner.
builder will hove the burden of proving that he did not build or improve for purpose of
sale.).
1, so owner of the property, am exclusively contracting with licensed contncirs to
construct IN project (Sec. 70", Business and Professions Code:) The ConmcterY LI-
cerue law dons nes apply n an owner of Property who Wilds or Improves screen, and
who contract for such project with a contractor(,) licensed pursuant O the ConlrOlofs
License law,
❑ I em eaempl under Sec: ,B 9 P C for his reason
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of do, following declamation:
ave and will maintain' a Cenifkne of Concert in se161nsure for Worher'a Compen-
sation, as provided for by Section 3700 of the labor Code, for the performance of Ne
work for which thio permit is issued.
❑ 1 hove and will maintain Worker's Compensation Insurance, u required by Section
3700 of Ne Lather Code, fee the performance of the wort fm which this permit Is Wood.
My Workers Compensation Insurance cannot and Policy number an:
e�
Cartier. TfvC—PolicyNo.: C-240
CERTIFICATE OF EK EMFnON FROM WORKERS'
'
COMPENSATION INSURANCE
TIM; section need not Mcompleted 11 the permit I, ferrous hundrnddollare (elm)
or less.)
I comfy that In the performance of the work for which this Permit Is toad, I shall era
employ anypenen in any mormf an se m become subject t0lW Workers'i'OmpCNalien
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. aAct making this CeNOcnte of Exemption, you should
heroine subject o the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions at this Permit shall W dcemcd invoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them D a construction lending agency far the performance of
the work for which this permit Is Issued (She. 31197, Civ, C.)
Lender's Name
Lender's Md.
1 certify that 1 have mad this application and scum that the salvo Infom ation is
correct. I qme m comply with all city and county oNlNnm, and stale lows relating N
Wilding construction, and hereby allfDtiM mpnsamatlms of this city to enter upon the
above-mentioned proPeny for Inspection purposes.
(We) agree Ia save, indemnify and keep harmless the City of Cupenino against
liabilities, judgments, cone and expense, which may In any way seem against said City
In consequence of the Stenting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
Signal.. of APPlicanUCanin r Date
HAZARDOUS MATERIALS DISCLOSURE
Will the appincam or future building occupant more or handle humorous material
as defined by be Cupertino Municipal Cash. Chapter 9,12, and the Health and Safely
Code. Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes Nu
If a roof is installed without first obtaining an inspection, I agree to remove
Will Ncepplicanl ur fuumebuilding mupamuse equipment ardevice, which
hav�Nnm air ane=mone n de0ncd by the Bay Ana Air Quality Management
all new materials for inspection.
sun,
❑Yes Nu
I have mad the honrdons makrials mquirement under Chapter 6.95 of the Cali for.
nla Hat" $afmyCode, Sections 25505.25533 and25531.I understand thus IfNc Wilding
Jou rot currently hem .tenant, Nat h is my mspmihlllly b mdfy IW occupant of dm
nquinment uuWmalPriormlssuatmeer.ccrdncxworoceupaney.
Signature of Applicant Date
� 2i x
All roof coverings to be Class "B" or better
Owner ununnt" ant Dai