04090142CITY OF CUPERTINO
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BUILDING DIVISION PERMIT.(:`ONTRAC
BDILDINGADDRESS:
PALISADE BUILDERS INC
PERMIT NO. 04090142
WNAPIAM T-EVENSGRKPERMIT
ISSUE DATE
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SANITARY NO. CONTROL NO.
ARCHITEC (ENGINEER:
BUILDINO PERMIT INFO
BLDG ELECT PLUMB MECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
lob Description
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1 hereby affirm Thal 1 am licensed under provision, of Chapter 9 (commencing
with Section 70(X)) of Division 3 arrive Business and Professions Code, and my license Is
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NEW CONDO -.1102 SQ. FT.
License Class
Dale - Contractorator L
ARCHITECTS DECLARATION
1 undenund my plsm II be useJpublic rernrds
Licensed Professional
OWNER -BUILD RDECLARATION
1 bemhy affirm that I am exempt from the Catalogers License Lvw for the
following moon. (Section 7101.5, Business and Pro(cssinm Cole: Any City Or county
which requires a Permit to enmmuct, alter. Improve, demolish, at repair any structure
prior N its issuance. alw requires the applicant for such permit to file Asigned statement
Sq. Ft. Floor Area
Valuation
that he is licensed purseamm me provisions of NC Comractor'aLacmc isw(Chapmr 9
(commencing with Salton 7") of Division 3 of be Business and Profession, Code) or
8127567
that he is csempt Desefrom and de, bolt for tin alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by my applicants far a permit subjects Nr applicant to a civil penalty of
am mom Nan five hundred dollen (SSW).
❑ I, as owns of" property. ter myemployear with votes As Noir sole compensation,
31620084.00Re uired Inspections
will do Newark, and the arecum is eatimended oraRered Image (Sec. ION. Business
and Professions Code: The Conlnctors License isw does Out apply m an owner of
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property who builds orlmp(ovesda nand whodeeNah work himselforthrouth his
own employes, provided Natauch Improvements are not Intended creamed (mule IL
however, the building or Improvement is sold within one year orcompletion. site owner.
Wilder'will haus the burden of proving that M did not Wild or Improve r" purpose of
tete.).
❑ 1, as Owner of Obe property, am exclusively contracting with Ilttmed contractors to
construct she pmjem (Sec. 70th. Business and profenions Code:) The Contractors LI -
cense Law does our apply to an Owner of property who Wilds or improves daemon, and,
who contacts for such projects with a caroming.) licensed puManor to the Contractors
Llr.. Law.
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WORKERS COMPENSATION DECLARATION
ir 1 hereby x111. under prosily of perjury one et the following dalwtions:
a¢end will maintain aCenifinu ofComem to self -insure farWorkersComp m.
, u provided for by Section 370 of tic 1. ver Code, for the performance of the
work for which NH permit iv issued.
❑ 1 have and will maintain Worker's Compensation Insurance, ss mqulmd by Section
3700 of the laborCodo,f"Ne pegormmttof Ne wort for which Nis permit is l..ued.
My Workers Compensation Insurance carrier and Palley number am:
Carrier: M!Sa..57,C / - Policy No.:L�3.1A
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not becomplemd If Ibe permit H for one hundred dollars (SIM)
or less.)
1 certify Net In the performance of the work for which this permit Is heard. I shall nut
employ any person in any manner an an b become subject to lhr Workerf Compensation
Laws of California. Date
Applicant '
NUTICETO APPLICANT: IL after making this Corneum of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall W deemed mocked.
CONS RUCOON LENDING AGENCY
I hereby &Mrm that there lis construction lending agency for ted perfurramcc of
dm work for which this permit H Issued (Sec. 3097, Civ, C.)
Lender's Nurse
Lender's Address
I modify that I have read this application and me that the above Information Is
carted. I all= to comply with all city and county on inamsund sum laws nlating 10
Wilding construction. and hereby auNorim mpankma iws or this city to enter upon be
above-mentioned progeny for Interaction purposes.
(We) agree to saw, Indemnify and keep harmless the City of Cupenin0 losing
liabilities,judgments, cats and expenses which may in any my acme against said City
in consegmmo of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS,
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Re -roofs
type Of Roof
signature Ofjpplrwon.,Van,
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding Occupant store"handle haurdous material
As defined by the Cupertino Municipal Code. Chapter 9.13, and the Health and Safety
Carlo. seetiam zss3z(a)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant orfutumbuilding Occupant use equipment Or devices which
hardoair contaminants u defined by the Bay Amo Air Quality Management
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all new materials for inspection.
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I have mW the ha7ardun materials requirements under Chapter 69S of ted Claim.
nla Health Ar Safety Codc, Seen" 25505,25533 uW 25530.1 eaderan d We time Wilding
does at curtemly have • enang, Nu It Is my resp nobility m reify the aecup., of the
requirements which mug W met prior to issuance of a Ccnileam Of Occupancy.
I Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner Or anthonz, gem Dau