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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090189
0 ERS AME:
PERMIT ISSUE DATE
C:
SANITARY N L NO.
ARCHITECTBNOINEER:
BUILDING PERMIT INFO
BLDG ELEcr PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 h.mby afOren that l em licensed under provisions M Chapter 9 (commencing
with Student 7000) of Division D of dm Boaineu and professions Code, and my lineme Is
in mu forte and efilm' R3R0�'r L
License Cl e C..
onto �i.s (• a a.� candnctoa d�
NEW CONDO - 1057 SQ'. FT.
ARCHITECTS DECLARATION
I understand my plum m used
Licensed Professional
0 :B DER DECLARATION
1 hereby aBrm that I am exempt from Lha Conlramora License Law for the
fallowing mason. (Sudan 7131.5, Business and Profession Code: Any city or county
which mquire a permit to construct. alter. improve, demolish, or repair soy stratum
prig to its issue=. also acquires Ibe applicant far such permit to rile a signed staematn
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant la IIIc provisions of die Contractors License Us, (Chapter 9
(commencing with Section 7000) of Division J of he Business and Profession, Code) at
that he Ie exempt dominant and the hub for due alleged exemption. Any Waledon of
APN Number
Occupancy pe
Section 7011.5 by any applicant for a permit subjects the applicant to a civil penally of
not more than row hundred dollen ($500).
C] I, As Mass ofthe property, or my employees with wages u their compensation,
31620084.00 Required Inspections
will do the work, and the struca,is notetended oroaemd forsake(Sec.7D44. Business
and Profetsimu Cade: The Contractor. License law don nal apply M in owner Of
q P
prapenywho hulldsal improms thereon. and whados aahwork Mmnlfm though his
awn employtua, provided Net such improwmenu are not Intended ooRend for ole. IL
howawL the building or improvement b sold within oo year of completion, the Owner.
builder will Mw the burden of proving that he did not hole or improve for purpose of
sale.),
❑ 1, es owner of the property am exclusively contracting with licensed contnetan to
constrocl the project (Sec. 7014, Business and Professions Cade:) The Cottnctor's U.
cane law dos not apply to an Owner of property who Wilda m improve 0mrean. and,
who contracts for such pmycu with a contrecbr(O licensed punmm to the ContnmMs
License Law.
❑ 1 am exempt under So. . B & P C fm this moon
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affbm under penalty of perjury, one of the following declarellans:
em and will meinuln •Cenirieu of Consent to sel6lnanOr fm Worker's Compe.-
tion, u provided for by Section 7700 of the tater Code, fm the Performance of the
work for which Nis Permit is issued.
❑ 1 hew and will maintain Workers Cempewdan Insurance, u required by Section
311, f the labor Cade, fa the performance of the work for which this permit is Issued.
My Workers Compensation Insurance carrier and Policy number are:
Center: �'S%x)r' Policy No:/7A/L032.53.^
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thin aCClen rated MI he completed ifft permit is (mon handnddallan (SIM)
m ICSL)
that In performance Of the work for which this Permit is lead. I shall ata
Pthearent mannerane tohecome subject tiw WOhen'CompemnlOn
employ orinany
LawsGlia. a
Laws of Celifomie. Data
plicant
NOTICE TO APPLICANT; IL afar making a Cenifi.ao
NOTICE
LAWdyou ushould
mat
n pmldons of the tabu Crdc, you mm
become subject to the Worker', the
forthwith comply ankh reek prevision or this permluhallbedtumW mokad.
OrCompewhis
LENDING AGENCY
1 beauty air,. that them Its construction lending Agenry, for the perfmmwu of
the work rte which this permit Is issued (Ste. 517, Clv, C.)
Nam.
Imdur, Address
I codify Nat I have read this application and state that the @bow information Is
I all to comply with all city and county ordinances suss laws misting to
building consdmction, and hereby authodm reprommaiwsof this city to enter upon the
abovomentioned property for Inspection purposes.
(Wu Agree to saw. Indemnify and keep harmless the City of Cupertino against
Iiebllides, judgments, costs and cxpem nwhich may in any way aoune aPimt mid city
In connguence of the flooding of this Permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REOULATIO —
Re -roofs
Type of Roof
^2�
Signature of Appllam/ mudrwt Date
HAZARDOUS MATERIALS DISCLOSURE
Will its applicant or fulurc building occupant eon m handle hassNous material
As deDnad by the Cupenlno Municipal Code. Chapter 9.12. and the 11n10 and Safely
ante, Sectio. 255324)?
All roofs shall be inspected to any roofing material being installed.
,,,,{;,,,
❑sem 21",
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prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant ter future building acupant am equipment or devims which
havardous air commlimnu an defined by the Bay Arc& Air Quality Management
all new materials for inspection.
Ott? /�,.�/t'`v°.--
❑Yes
Y
I hive Orad the Mssrdos materfeh nequimmcnu under Chapter 6.95 of the Califor.
niaHulth&Safely Code•Sudiau BM5.25515and2555e.lundenwalthmifdc Wilding
dos mal currently haw a enml, Lou it is my respomladlity to Mary do aulmanl of as
requirements which bemel Prier ld in.ano of. caOlrnate ar Occopancy.
nature of Applicant Date
O
All roof coverings, to be Class "B" or better
Owner at authorize Dam