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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
'°C,QN,T.1tA-CTU�i�,INVORMATII.OtN� ,
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT No. 04090153
OWNER'S NAME:
PBRMrr L%UEDATE
E:
SANITARY CONTROL NO.
ARCHITEC MNOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description _
1 hereby Affirm that I am licensed under provision. of Chapter 9 (commencing
with Seen.. 70(1)) of D10.lon 3.f No Business and ProfeWons Code, And my lice. Is
In rest mret and erfaL i%38oH6
NEW CONDO -1087 SQ. FT.
Dkme As, CV-_�ConLic.p
Date w'r Con
DECL
ARCHITECTS DECLARATION
I underslanJ my Phan ehA d as p M1 oral.
Licensed Professional
DoorER -BUILDER DECLARATION
1 hereby affirm that I em exempt from Ow Convamors License Low for the
following mason. (Section 7031.5, Business nd Professions Code: Any city Or county
which require. a Permit to construct, alter. improve, demolish, or repair my strectum
poor at its issuance. Alan requires, the applicant for such permit to rile a signed statement
Cetibactari Liavc Law (chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed punuanl In the pmvi.l. of the
(commencing with Section 7(100)of Division 3 of the Business ase Norceal os Code) or
1
that he U exempt therefrom and de: basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.3 by any Applicant for. permit subjects the Applicant to a civil Penally of
not mon Nm five hundred dollar, ($500),
0 1. as owner of the property, or my employee with wages ax their male compensation,
. Required Inspections
will do the work. and the structure is notinunded oroRend boxes, (Sec. 7011. Bwhmu4
And Profeukts Code: The Contrutoh License Law does no, Apply to an owner of
q P
propeny who Wilds, or improves d¢reon.and whodoeuah work Mmulforthrough his
ownemployces, provided that such improvements arc not Intended ormlered torula IL
however, the building or Improvement Is sold within one year of completion. the owner.
hulloes will have the burden of proving Nat he did not Wild or improve fm purpose of
Allo,).
❑ 1, e. owner of the property, am exclusively contracting with licensed contractors to
construct the pmjat (Sec. 7094, Business And Professions Coda) The ConRutors Li-
cense Low dues not apply to An Owner of property who Wild. or hnprow Ouneon, and
who controls for such projects with a contractor(,) licensed pursuant to the Contractor.
License Law.
❑ l em exempt under See. ,BkPCIerthismuon
OwnerDate
WORKER'S COMPENSATION DECLARATION
1 hereby ARrm under penalty of perjury one of the following dalsnlions:
haw and will maintain a CeNftau of Comm (a self-inaure for WorkersCompm-
Lima. As provided fm by Section 3700 of the Lester Code, for ties performance of the
wM for which Nis permh Is issued.
❑ I have and will maintain n workers Compensation Ins, m4uimd by Section
3,, of the Lester Code. for the performance of the work for which Nis permit Is Issued.
My Workers Compensation Insurance carder and Policy number art:
Corder: jg/9.7�Ji.G SYC Policy
CERTIFICATE OF EKEMPDON FROM WORKERS'
COMPENSATION INSURANCE
('ITU action need not becompleted Bthe permit is foroue hundred dollars (SlOO)
or less.)
1 ceAfy Not in the performance of the work for which this Permit Is led.d. I .),All ma
-
employ any person In any manner an As b become subject total Workers,' Compensation
Laws or Califonia. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you MoZ
become anbjat m the Workeh Compensation provlthm. of the Ubor Code, you must
forthwith comply with such provlMru Or this permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby Arnim that Nen las construction lending agency for the Performance of
the work for which this permit is issued (See. 3097, Civ. Cd
Lender. None
Lewers "it=
1 1 cmity that 1 have reed this Application W sum that the Abow immomNoO Is
coOeck I agree to comply with all city and county ordinances and state law$ relating to
building construction, and hereby Audition representatives of this city to enter upon lW
i above-mentioned propcny for Impaction purposes.
(We) agree to caw. indemnify And kap humorless the City of Cupertino against
j Imbllhmajudgmenu.cam and expenses which may in my way ucree Saint mid City
I APPLICANT UNDERSTANDSconsequenof the Soliffifill ofIAIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
�f _ tyt2f- 15
Signature of APPICMUC�or Data
HAZARDOUS MATERIALS DISCLOSURE
Will the Applicant sir future building acup.m.mn or hawk henodo., ..,coal
As dcfioed by the Cupertino Municipal Code, Chapter 9.11. and the Health and Safety
sea SaoOan lss3z(.)7 ✓
All roofs shall be inspected prior to any roofing material being installed.
❑ Ye.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or hilum W Ing Occupant use equipment or devices which
11 t heerdous air contaminants u defined by the Bey Area Air Quality Management
all new materials for inspection.
latricl?
❑Ya
rChapter Califon
Ihave read the lesardansmakdai25533
Ame5334.I Mile:
15A3 Armauld .I ifdn Wilding
Ola Ncalth65Aletyhave
inM amity
daos net currently have a tenant that II U my respensihility m notify the occuPand of the
A iectionshat it i ft o
requirements which most he met poor to issuance tiff Cendicak of Occupancy,
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owncr or mthodnda eel Dano
a