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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090187
OWNER'S NAME:
PERMIT ISSUE DATE
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SANITARY N OL N0.
ARCHITECr/ENOINEER:
BUILDING PERMIT INFO
BLDG ELECr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lois Description
I hemby affirm IMI I am licensed under Provisions of Chapter 9 (commencing
with Section 700X)) of Division 3 of the Business and Profeedom, Code. and my license is
to full fame and eff,ct. q sso-I
Licenw Clea Lee,
NEW CONDO - 1106 SQ: FT.
- ,
Dam 6 Contractor 497
ARCHITECTS DECLARATION
1 undentnd my plana a and u public record
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Licensed Professional
UILDER DECLARATION
Oat
I hereby affirm Thu 11..Bumph from the Conmaocs License taw for IM
I am
following massa. (Section 703 Code: Any tiny of county
alter. and PreImprove,
demolish. any moment
which sequlrce a permh onstr t. alter. Improve, demmhhe fierepair
sere,
Re the a,ig
pdorlasl iensedC aharnquirenheapplicant teeth pencil
Sy. FL Floor Area
Valuation
Ltilt. UW (Chapter
that heentintnwit PunomttotM the Commences Llecnse MwlC
OfprOviairmil sionf
Coca) or
(commencingwith Section OfDivisionf3 shthe Business and ProfessionACmle)or
eged
Nal be b esempt Nertfrmn and the bub far she tllagha exemption. Any violation Of
and
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil Penally Of
not more Nan Rw hundred dollars ($500).
❑ 1.uawato of the Property, u my employees with wages u their WIC compensation,
31620084.00 Required Inspections
will do the work, and to smuture b noumended or offered for ule(See. 7044, Business
earl Profeumns Code: The Connector's License Law docs not apply m an owner of
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property who builds cr improves thereon, and who dmnueh work himself or through his
own employ.,, provided that such Improvements us not intended proffered forgets. If,
however, the building or Improvement Is sold within one year of comptedon, the Owner.
builder will hew the burden of proving Nn M did not build or Improve far purpose of
earn.).
0 L as Owner of the properly, am exclusively contracting with licensed contracture to
convect the projacl (Sec. Business and Professions Code:) The Connactm's Li.
tenet taw time not apply to an owner of property who Wilds or Improves tierton, and ,
who contracts for such prejeca with a eonuactor(s) licensed pursuant m the Contractors
Lleen, Law.
❑ I am eaempl under Seo. ,B@ P C for this reawn
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby in. under penalty of perjury, owe of the following daelantia,:
hew end will maintain a Certificate of Consent self-i,un for WorkersCompen-
color, u provided for by Section 37M of me Labor Code. for me ped., ante of tM
work for which 6h permit is issued.
1 have and will maintain Workers Compenulion lesummen. se rtquireA by Section
3700 of 6e labor Code, for the Prof.... of de work fee which this permit is Issued.
My WOrkeM1 CampenuOOn Insurance carrier and Policy number
Center. M A.T,S%e C �ii t^Pollry No.:C-�0��'Z%
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(rhh section need not hecompleted if the permit Is foram hundred dollars (SIM)
or leu.)
I cenify then In the p ffernu ncc of the work for which this permit Is tuned. l shall not
employ any person In any manror w u to become subject to the Workers' Compensation
Laws of California. Due
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Eeemption, you should
become subject to the Worker's Compensation provisions of the Labor Cods, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
LENDING AGENCY
1 hereby affirm the, Nem Is a constroctinn lending agency for the pururmance of
Ne work for which this permit b Issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I cenify Nal I haw read this application and ma that the above Informed" Is
correct, 1 agree to comply with all city and county ordinances and stem laws mining to
building construction, and hereby authorles, oresa,mlvu or this city to enter upon the
above-mentioned ProIsr1Y for Inspection purposes.
(We) agree to raw, indemnify and hep harmless the City of Cupertino against
Iiabllides.judgment, costs and eapeases which may In any way accrue against old City
In APPLICANT UNDERSTANDSIAND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
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Re -roofs
Type of Roof
SiStm ure of Applicant/ Dam
HAZARDOUS MATERIALS DISCLOSURE
Will she applicant Or future building Occupant store or handle huardous material
Is defined by the Cupenlno Municipal Cade. Chapter 9.12. and IM Health and Safety
We, Section 25532(a)7
Oyu /Thio
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
WIII the applicant or future Wilding Occupant an equipment or devices which
h gushou air eonarrhant u dented by the Bq Area Air Quality Managcmem
all new materials for inspection.
grit?
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I have mad the MssMms materials mquiremems under Chapter 6.95 of the C4lifon
nitHal" Safety Code, Seldnu 25505, 25333 and 25534.1 understand! 6u lfthe Wilding
does tet curmmly Mw a tenant, Nn h t my ne ,mllitya mti(Y,be peepw, of the
mquirement which mug be met pool m tun of Cern currency
Signature of Applicant Date
s
All roof coverings to be Class "B" or better
Owner, suthadude Dee
em