04090186CITY OF CUPERTINO
• +� xme r �) I< rs r a
BUILDING DIVISION PERMIT
'bX2 vIAnot.;
;C0NTRACT0R:;i�N
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO. 04090186
OWNER'S NAME:
PERMIT ISSUE DATE
E;
SANITARY NO. CO OL NO.
ARC HITECDENGINEER:
BUILDING PERMIT INFO
BLDG 'ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that 1 am Iicenmd under provisions of Chapter 9 (Commencing
with Section 70018 of Division Sof duo Business AM Profession Code. and my Licenm Is
Li��°�WinOert�"' $�L 3 6 6
NEW CONDO -1552 SQ. FT.
0
Dam rsclor �Canl-t
ARCHITECTS DECLARATION
I undemad my s I k umelu public mernrN
Lrtcosca Prof..,.All
OW NER-BUILDER DECLARATION
I hereby &Man that 1 em exempt from IW Comrmtefs Licenm law for 1W
.
following mason. (Section 71111.5, Bawl and Professions Code: Any city of county
which requba a permit to Consumer, .1mr, Improve, demolish. or repair any Stan Wro
prior in its issue=. alms require the applicant for such permit to file a Signed atemenl
Ft. Floor Area
Valuation
dust M b licensed Furman, to the Pr AbAWaf We Conlrmmfs Ucenm Law (Chapter 9
Sq,
(commencing with Section 7") of Division 3 of 1W Business and Profession Cam), or
Wt fie b exempt memfrom and the Dub for the alleged exemption. Any violation of
APN Number
Occupancy Type
Stenon 7031.5 by any applicant for a permit aubkmu the applicant 10 S civil peaghy of
not mom dun five hundred dollars (SM
❑ I, uownerofthe property, afmyemployw with "WAS their Cole compewtion,
Inspections
will do the work.md themucture is not intended m"Deml(.,all,(Sm. 7044, Business20084.00
Act apply an oef of
and Profusion Code:CommitteeseCommitteesnm es Linlaw does eInw
Required
q P
property who belkW ar tmprovea dueseon, and whe dom mch wank himself m through hit
own employes, provided that such impmmmenu Am nm intended oro0ered forule. IL
however, the Wilding or improvemeal Is mid within one year of completion. the ower -
W ilder will love the burden of proving that W did rot Wild or Improve for purpose of
ASIA.).
❑ 1, as owner of the Property am aclaively contracting with licensed eo"um Ars to
construct six project (Sec. 7044. Business and Professions Code:) The Conincta'a U•
Bose law docs not pply m an ower of property who Wilda or improv, thomm. and
who contracts for such pmjecm with a cmnlncfor(s) licensed personal to the Contranof,
License law,
❑ 1 am exempt under Sec. . B A, P C for this means
owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby &Rom under penally of perjury one of the fallowing dmlarallom:
haw and will maintain a Certificate ofCammnl to self -insure for Workers Compere
ssdon, u provided for by Section 37011 of the Labor Code, for We performmce of the
walk for which this Permit it issued.
❑ 1 have and will maintain Worker's Compensation Instance. As required by Section
311 of We labor Code, for the performance of AS work for which ibis permit is Issued.
My Worker, Compenmlion'ZoaroY cmier and Policy number art:
Cartier: 6M a%.1<_S%.-714C Policy No.: QACy-21S 37
CERTIFICATE OF EKEMPnON FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not W completed ](the Permit IA (mow hundred dollare (6101)
or leas.)
I certify that In the perfomence of the work for which this Permit is Issued. I shall not
employ anypefron in any manner so an to become subject to the Warkeri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: IL after making this cenifieste of Exemption, you should
become subject to the Workefe Compennllon provision, M the labor Code, you mal
forthwith comply with Such provisions m this pennil shall he dictated revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affmm dust there ill construction lending agency for the performance of
the work for which this permit Is lulled (Sec. 3097, Civ. C.)
Under', Name
Umm,'. Address
1 cenify that 1 have rand Nb appIlcAd.n ab sou that the above information is
correct. 1 aline in comply with all city and county aNlnnces and Sum Awn miming in
Wilding e.nafmetion, and hereby amhorim rmpremnlativeS mild. city I. enter upon the
above-mendoned property for Inspection purposes.
(We) agree to ave, indemnify and keep hmadea the City of Cupenmo against
IiabllWe, jual ments,eoa and expenses which may in any way @come apWueld City
In consequent. of the g .ming of IMS Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Of Roof
N--21
Signature of ApplianUCont for Dam
HAZARD ATERIALS DISCLOSURE
Will NeapplicAmor allure building occupant stem orhandlc haesrdoa material
AS darned by the Cupertino Municipal Code, Chapur 9.13. Soul tie Health tad Safety
dam, Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
pYa 0
If a roof is Installed without first obtaining an inspection, I agree to remove
Will the applicant or fulare bu ding =upset use, equipment or devices which
nns m
haranair..Mmints ss de0ncd by tie Bay Arca Air Quality Management
all new materials for inspection.
uviaT s�
❑ Ycs
I have read the h..smaurial,equimmenuunderCMpw6.95ofthe Califm.
'
.in HealthA, SafclyCode. Section, 25505.25533 and25534. l undmsfand thatlftie (wilding
deal an, currently hoc a Wrens, duan II b my reaN.Ibilily m nodfy the occuPml of the
mqubcomma which mum be mel prior m issuance of a Certificate of Occupancy.
nature of Applicant Date
'2� ®
All roof coverings to be Class "B" or better
Owner
o Smhonmdagent Dom