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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO, 04090190
OWNER'S NAME:
PERMITISSUE DATE
E:
SANITARY NP. L NO.
ARCHITECDENOINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
D
LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby alRrm that 1 am licensed under provisions Of Chapter 9 (commencing
with Section 70OA of Divlalm 3 of dm Busimusand Profeulam Coda, and my Ilceme is
;,full forte end effect. 4 AAs 13 o4 o(::;,
P
NEW CONDO - 1057 SQ. FT.
License Cleu
Dam ='Contrmmr r
ARCHITECTS DECLARATION
I understand my plana alull bo
Licensed Pr
OW NER-BUILDER DECLARATION
1 hereby aOLm that I am exempt from stns Contractors License Law for the
following memo. (Suction 7031.5• Business and Prafesslons Code: Any city ,r county
which require{ a Penult to construct. alcor, improve, demnlnh, or repair any structum
prior to its WUMM. aim requires the applicant forsuch permit to file a signed statement
Sq. Ft. Floor Area
Valuation
,hat he is licensed pursuant to lad prevision= of the Connector. License Law (Chapter 9
(commencing with Section 7") of Division 3 of the Busineu and Professions Code) or
Nn he Is exempt themfrom and the basis for the alleged exemption. Any vioudon of
APN Number
Occupancy Type
Section 703115 by any applicant for a permit Subjects the applicant ro a civil penalty of
not marc than five hundred dollars (5500).
❑ I, u owner ofthe property, or my employees with wages v their mlc compensation,
3162 O O84. 00 Required Inspections
will do the wah.md the suucmre lsmt Intended moffered for{ak(Sec. 7044, Business
and Professions Code: The Communes License Law does set apply m an Owner of
9 P
propeny who builds or improws usumm. and who doestach work himself or through h4
own employees. provided that Improvements am not Intended oroficrW for Sale. If,
however, Ac building w tripmvemm, is mid within am tsarof compledoo. Ne owms.
builder ME haw the Widen of proving mat W did ml Mold or Improve for pulp. of
SAM).
❑ 1, a owns, of the progeny. am exclusively contracting with licensed contractors to
construct the pmject (See. 7144, Busineu and Professions Cade9 The CmMitsel U -
cense law does not apply A an owner of property who build{ or Improve, thereon, and
who contracts for such projects with a contrmtor(s) licensed pursuant m the C(nnsetora
License Law.
❑ I am exempt under Sec. ,B&P C for this mason
Owner Date
WORKERS COMPENSATION DECLARATION
I hereby a10rm under penalty of perjury one of the following declatal a s:
ave and will mal,Yln aCeninnmaf Cement to self -Inman fm WortrM1COmPcn-
mien, as provided for by Smiton 3700 of do labor Code• for On Performance of rite
work for which this permit T issued.
❑ 1 hive and will maintain Workers Compenudon Inmrana, u required by Section
3700 of the labor Cade, for An performance of Ae work fm which this Permit is issued.
My Workers Compensation h m ince carrier and Policy number are:
Carrier. sA?�i7: C Policy No.:!'aL�r]y���Ci 33
CERTIFICATE OF E) EMPTON FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not W completed I(Ihe permit M forom hundred d,Ilars({If )
sir Ices.)
I unify Ohm In the perfomunm of the work for which this permit Is Issued, I shall not
employ any Tureen In any manror an a to become subject the Worker' Compenwlon
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making AN Confute of Exemption, you should
became subject to the Worker's Compensation provision{ of the lahor Code• you must
forthwith comply with such provisions or this permit shall he decreed mrolo d.
CONSTRUCTION LENDING AGENCY
1 hereby aRmm Nn there is a construction lending agency fm 1W performance of
tins work fur which this permit Is issued (Sec. 3097• Civ. C.)
lenders Name
Lenders Add.,
I unify that 1 have rad Al.application and tum that the show Information n
cermet. 1 agree to comply with all city and county ordinances and rote laws mladng m
building COMILM110a, and hereby authodre representatives of this city to toter upon the
above•meMuned property for impaction purposes.
(boa) agme to an. Indemnify and keep harmless the City of Cupertino against
IlablllOea.judgments, cons and expenses which may In any way accroc against Said City
In consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
If'��'�
a -roofs
Type of Roof
Signature of Appicen ontrmlor Oate
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant ams or handle hvardous material
as defined by the Cuperdno Municipal Code. Chapter 9.12. and the Health and Safety
ode.aa2ss32(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ No
[3 Tres
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant arforam WndIng amap.,t 9m regmnmrem at sear ma which
hvardous alf contaminants As defined by the Bay Arca Air Quality Management
all new materials for inspection.
strict?
❑Yes „41,
1 have read the heardAmsmaterials requirements underChopwr 6.95 of the Caller.
nia HealthAt Safety Code, Scums 25503,25533 soul 25534.1 understand that If thc Wilding
docs not currently how a tenant, Net It Is my responsibility to notify be omul mt of me
requim:; rats which aBWmctpriar to n=om=eon eerdneate ar Qenpaney.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner Dem
un aCem