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BulLDINr ADDRESS:
PALISADE BUILDERS INC
PERMITNQ4090185
OWNER'S NAME:
PERMIT ISSUE DATE
04/20/2005
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECTIENOINBER:
BUILDING PERMIT INFO
BLDG ELECT PLUM0B MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby alarm Nn at I am licensed under provisions of Chapter 9 (commencing
with Section 70rA)) of Divlalon 3 ofthe Business and Profoundness Code. and my license b
In full farce andefUct. `
NEW CONDO -1552 SQ. FT.
License CI _ Uc. N
SD§Cr
ARC D�CURA710N
all Im;S
1 understand my plain still he uscy4 naklie rt a�—
/I
Licensed Profcuional
OWNER -BUILDER DECLARATION
I hereby of on that I am exempt from also Conusmm's License Law for the
following rcunn. (SmWn 7031.5. Dust= and Profession Code: Any city or County
which requites a permit to construct, alar, Improve. demolish, or ¢Fair any mnatum
prim in am isauace. also requires tin applicant faranch Permit to Ole a signed gatemen
that he is licensed pursuamm the pmvislmu nfthe Contracm's License LA. (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Profession Code) or
$183942
11111 he is exemPL therefrom and the 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
.at ream than It. hundred dollars ($500). '
0 I, u ower of the pmpmy. m my employ=wio wgos u the4 sok Compensadom.
31620084.00 Required Inspections
win do the work. and ate structure b atktended a,onertd image (Sec. 70th. Basica
ad Profusions Code: The Comseme, License Law d= not apply In a owner of
property who builds ser Improwa themon. ad who dos sue h work himself ser through his
own employees, provided thatsoch imprmemenuae not Intended moQemd for sale, If,
however, the building or improvement 1, sold within one year of completion, the owner.
builder will have that hurda of proving that he did am bard or Improve for purpose of
sale.).
0 1, m Cruor of the Property, &m exclusively Contracting with licened conuuma in
construct the project (Sec. 711a, Be lows and Rofasaiaos Code:) The committees U.
ecose Law d= not apply to an owner of property who Wi1N or Improves thereon. and.
who contracts for such projects with a contractor(s) licensed pursuant to the Commerce,
License Law.
0 1 am exempt under Sec. . B & P C far this mann
Owner Data
COMPENSATION DECLARATION
I hereby grim under penalty of perjury aro of the following dechurado :
pIWORKERS
hero and will mammin ACenifiod of Cauent in aelf-0nure for WmkeesCompen-
sation, u Provided for by Section 3700 of the labor Cade. for the performance of the
work for which this permit is issued.
0 I have ad will maintain Workers Compensation Ingr ance, M required by Section
3700 of the Labor Code, for the performance of the wort forwhich this permit is issued.
My Workeea CompemWon dsunna carrier ad Policy number art:
Cartier. 1'fl.fC TTt—
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
from mc0o need act be Completed it the permit Is fm one hundred dormer is 100)
or less.)
I certify that In the performance of thc work fm which this permit is issued. l shall net
employ any person in my matter a u in become abject in the Workers Compenation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL afar making this Certificate of Exemption. you should
become abject m the Waher's compensation provlams of the Labor Cade. you moa
forthwith Comply with such providon or this Permit Mall be dcemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that dart isaconsucatu n loading agency far the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Namo
Lenders Addrm
1 certify that I haw read this appik11io and sum that the &bout infmmatio is
cormtx 1 agree to comply with all city ad County ondinances and sum law mladng he
building construction, ad hereby stalactite rtprescnutiws of this city an enter upon also
shove -m rdi...d property for inspection purposes.
(We) agree to sew, indemnify ad keep humleu the City of Cupertino against
liabilities, Judgments, cuts ad expenses which may in ay way acme against hid City
in consequence or the grating of this Fumil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Type of Roof '
Signawrt of ApplluHAZARDO Dete
HAZA RDOUS MATERIALS DISCLOSURE
WIII theapplicantCaper or factum building occupant atom or handle h
Health am.terid
u defied by the Cupertino Mu pa Code. Chapter 9.12, sed the Halts ad Safety
Cede, Section 25533(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or factum building occupant use cyulpmcnt ser devices which
Ir harudnu. air contaminants as darned by the Bay Ama Air Quality Management
all new materials for inspection.
District?
❑Yes
I haveread 1111 baallosmaenab requirement underChapter6.95 of the Califon
nu Health& SafayCodc. Se tians25305.25533 sed 25534. i understood! Ihaifth, binding
does not currently haw a un ren that it u my rm arabiiity to notify the eccupat of the
mquimmenu which mug met ptiarmuauaccofa Cerifiosteof Occupancy.
ignature Of Applicant Date
All roof coverings to be Class "B" or better
Owner
or tulhori n1 Date