04090188CITY OF CUPERTINO
%*�r°7�7r(s+.+n�
BUILDING DIVISION PERMIT
�a.
�4Qa.1vJLV
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITNO. 04090188
OWNER'S NAME:
PERMIT ISSUE DATE
E;
SANITARY . 0 OL NO.
ARCHITECTAENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CON RACTDR'S DECLARATION
Job Description
1 Wrtby affirm that 1 am licensed under previsions of Charm, 9 (commencing
P
with Sutton 7000) of Division Sof the Butimrs and Profession, Code, and my license is
in full force and effect.
umnhe a.,a B Lk.N -4HDN Co
NEW CONDO - 1106 SQ: FT.
Dam j�37-�Cuntranor AZrSAIO=
ARCHITECTS DECLARATION
I understand my plass Will W hlk ¢corm
Licensed Professional
60 ER7B I ERDECLARATION
I hereby affirm that I em exempt from shp Contractor, License Law for the
following mason. (Section 7031.5, Buslnuf and Profestiont Code: Any city at county
which requires a permit it, construct, aler. improve, demolish, or repair any structure
'
prior to its issuance, also requires the applicant for such permit to rile a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed punuant In the provistou of the Contractor'Weer¢ LA. (Chapter 9
(commeuing with Section 7") of Division of the Business and Professions Code) or
that he is exempt tiemfrem and the bub for Use 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
not mom than five hundred dollar, ($500),
I, As owner of the property, or my employees wish wages as their sole compensation,
31620084.00 Required Inspections
will do tW work, and than serum, is not intended or offered fu sale(Sm. 7014, Butineu
and Professions Code: The Comishmofs Liam law does am apply M an owner of
9 P
propeny who builds or Improve, Neuron, and who does inch wank himself or through his
ownemployas, provided that such Improamenta arc notinknded oroffered forud& if,
however, tW Wilding or Improvement is held within off year ofeompletion. the owner.
bulldu will have thin burden of proving chat he did ret Wild or improve for purpose of
sale.).
❑ 1, as owner of lie property, am exclusively contracting with licensed contractors to
constmcl tW project (See. 70". Business aM Profusions Code* The Conowler's Lf.
ave law does not apply in m owmr of property -be Wilds or Impovo cheseon, and
who contacts for such projects with a contractorf.) Himself pursuant se the ComraseM1
License Law.
❑ Iamexemplunder Su, .B&PCformbmuon
Owner Dow
WORKER'S COMPENSATION DECLARATION
I hereby AM. under p golly of perjury ane of the following deelarnlam:
sve end will maintain aCenlfiesse of Comant to self-bnum fm Werkeri Compen-
talion, u provided for by Section 3700 of the Labor Code. for the performance of the
work for which this permit is issued.
❑ 1 have and will maintain Worker', Compensation Insurance, u required by Scctton
3700 of she labor Cade, for Use performance of the work for which this permit Is issued.
My WoheM1 Cnmpewtion Insurance carrier and Polity number art:
Carrier: 41 4JeA7 ' - 92 Policy No.: 2S'8a;A.
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATION INSURANCE
(This Mmlm stud nor W canpleled Edo Permit is f vooe hundaeddnllan (211111)
or less.)
1 certify that in the prformana of the work for which this permit I, issued, l Mall not
employ any person In any MMMm So u to become Subject o tW Workers Compeunion
Lim of California, Dam
Applicant
NOTICE TO APPLICANT: If, after making this Ceniftcam of Exemption, you Mould
become subject to the Worker's Compensation provisions of the labor Code, you MUM
forthwith comply with such provisions tar this permit Muill be domed mvnked.
CONSTRUCGON LENDING AGENCY
1 hereby affirm that them In construction lending agency for the performance of
the work for which this permit is Issued (Su. 3[197, Civ, C.)
Leaden Name
LenmriAddress
1 unify that I haw: read this pplication and Marc that the above Information is
comet. I agree to comply with all city and county ordinances and suite laws relating to
Wilding construction. and hereby authusis rtpressmatives of this city to enter upon the
l abovcmenflOud property for Inspection purposes.
(We) agree to save, indemnify and kap homeless, the City of Cupertino gaiut
j Ilabllhles.judgments, core and expense, which may In any my accrue against said City
In conacquerm. of the APPLICANT UNDERSTANDS Aof IND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. -
Re -roofs
Type of Roof
an
Signemre of ApplkanU manor Dam
HAZARDOUS MITERIALS DISCLOSURE
Will Oe applicant or future building occupant more or handle haeardous material
As defined by the Cupertino Municipal Code, Chapter 9.12, and IM Health and Safety
.vLould, Son 25532(s)i
All roofs shall be inspected prior to any roofing material being installed.
Sao
If a roof is installed without first obtaining an inspection, I agree to remove
Will IW applicant inure buss ing occupant tau equipment or devices which'
haxwoous sir contaminants As darned by Ile Bay Area Air Quality Management
all new materials for inspection.
vic1T /•
❑Yes
I ham mrd she lberdnusmawrialimquimmenw underCMper 6.95 of the Califm.
ni,Heslsh&Safety Coit,SeeuoM255o5.25533Ru125534.lun&itwotuliftW Wilding
does act currently ham a tenant. that It is my responsibility An notify the occupant of she
requirements which must be met prim to issuance of a Certificate of Occupancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner or amh"rived agent me