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CITY OF CUPERTINO
BUILDING DIVISIONPERMIT�''�`
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BUILDING ADDRESS:
PERMIT 140.
10090 N WOLFE RD
PALISADE BUILDERS INC
n9n7no39
OWNER'S NAME:
PERMrr ISSUE DATE
PHONE,
2009
S A CONTROL NO.
n
(650)470-4700
ARCHr1ECTIENGiNEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
in full force and efrecL
TEMP PERMIT,ORIG #09050013, EXCVAT FOUNDTN
Date�Cl CCoontractor
FOOTINGS & INSTL FOUNDTN & BASEMNT REINFORCMNT
ARCHITECT'S DECLARA ON
SLB
I undersand my plans shall be used as public records
& BASEMNT RETAINING WALLS ONLY
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractors License Law for the
following reason. (Section 7031 S, Business and Professions Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the Contractors License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$100000
that he is exempt therefrom and the basis for the 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
W1 more than live hundred dollars ($3M.
316 2 0 0 3 7 . RO S E
❑ L as owner of the property, or my employees with wages as their sole compensation,
Required Inspections'
will do the work, and the structure Is not intended oroffered for sale (Sec.70".Business
and Professions Code: The Contractor's License Law does not apply to In owner of
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property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale If,
however, the building or improvement is sold within one year of completion. the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
-
Q 1, as owner of the property. am exclusively contracting with licensed mmntracum to
construct the project (Sec 7044, Business and Professions Code:) The Con=ies Ll-
ccrese Law does not apply to in owner of property who builds or improves thereon, and,
who contracts for such projects with a contractor(s) licensed pursuant to the Contracmes
License Law.
exem�u $�:. P C for this n
Owner s /jT��' Dae O
WIRKEWS COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury ono of the following declarations:
❑ I have and will maintain a Certificate of Consent to self -Inure for Workers Compen-
sation, as provided for by Section 3700 of the Labor Code, for the performance of the
wort for which this permit Is Issued.
❑ I have and will maintain Workers Compensation Insurance, as required by Section
3700 of the Labor Code, for the performance of the work for which this permit is Issued
'
My Workers Compensation Laurance carrier and Policy number am:
Carrier. Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(chis section need not be completed if the permit Is for one hundred dollars MOD)
or lest)
I certify that In the performance of the work for which this permit is Issued, 1 shall not
employ any person in any man r r u me subject to the Workers' Compensation
� �O
Laws of califon}je. Daly I ��
Applicant �,It .�/��
NOTICE TO APPU : 11, after making this Certificate of Exemption, you should
become subject to the Workers Compensation provisions of the Labor Coda you must
forthwith comply with such provisions or this permit shall be deemed revoked
CONSTRUCTION LENDING AGENCY
I hcroby affirm that there is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C)
Landds Name
,
Landers Address
I certify that 1 have read this application and sate that the above information Is
'
correct. 1 agree to comply with all city and county ordinances and sate laws relating to
building construction, and hereby authorize representatives of this city to enter upon the
above-mentioned preperty for inspection purposes
(We) agree to save, indemnify and keep harmless the City of Cupertino against
j liabilities, judgment, costs and expenses which may in any way accrue against said City
94s,
iin consequence of the granting of this PerrnlL
APPLICANT UNDERSTANDS AND wiL-L COMPLY WITH ALL NON -POINT
Issued by: DateU/
t&�-7— �eC
SOURG ONS.
i
o
y
Re -roofs
Type of Roof
Signadre of App ianUContractor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hrordous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Cade, Section 25532(x)?
C] Yes ON.
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
Will the applicant or future building occupant use equipment or devices which
emit hvardous air contaminants as defined by the Bay Anes Air Quality Management
all new materials for inspection.
District? 16
❑ Yes No
I bavc mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safety Code, Sections 25505, 25533 and 25534.1 undersand that if the building
docs not currently have I tenant, 11111 It is my responsibility to notify the occupant of the
requircmc which be met prior to issuance of a Certificate of Oc ,ter.
t-�.4' �1 "'r�
Signature of Applicant Date
All roof coverings to be Class'%¢" or better
Owner Dae
or sutharized agent