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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.
04090159
AM
FERMITi.'SUEDATE
SANITARY OL NO.
ARCHITEC iENO1NEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm hit 1 am licensed under provisions of Chapter 9 (commencing
with Section 70fkfi of Division 3 of the Business end Profcsalom Code, and my license 0
orce meene.Lwnc Cit., mLie.g 6 `
NEW CONDO -1111 SQ. FT.
Oa1e Co.
j
ARCHITECTS DECLARATION
1 un4• nand my Plana shall wed u pat Ile rte
Licensed Pnthuionai,
OWN •R -BUILDER DECLARATION
I hereby &ffirm that 1 am exempt from the Conlracmr's License law for the
following mason. (Section 703 1.5, Business and Professions Code: Any city or county
which requires a permit m con msel, alter. improve, demolish, or repair Any structure
prior In in issuance, also requires Me applicant for such permit to rile asigned sutemcnl
Sq. Ft. Floor Area
Valuation
that he is licensed Forwent to the previsions of the Conviviart Licence Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Profession, Cale) or
that he la exempt Therefrom And the basis for the alleged exemption. Any vw atfo. of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mom than five hundred della. (5500).
❑ 1, As owner of ted pmpeny, m my employees with w.ges u Nair mle compensation,
31620084.00 Required Inspections
ve111 og woh,.ndtbeawaumtanaammndedmaffemd fw..u(Seo.7044,13uelron
and Professions Code: The Conuaemr's License taw does not apply so an comes of
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property who builds or Improves Merton, and who does such wank hi mself w through his
Own employees, provided that such tmprovemmu a. not Intended wroRered forula If,
however, Ne Wilding or impowasnot wools within oro yen of COMPlegoO. the omm-
Wilder will have site Inrdcn of proving Nest he did net Wild Or Improve for Purpose of
sale.).
❑ 1, as owner of the property, am exclusively contracting with licensed contrsemrs ve
construct the project (Sec. WWL Business and Professions Code:) Ilia Conuacter'. Li-
cense law docs not apply to an owner of property who Wild. or improv themon, and,
who contracts for such projects with a conuactm(q licensed pursuant to the Comate'.
License Lew.
❑ 1 am exempt under Sec. . B Ar P C for this MUD"
owner Dau
WORKERS COMPENSATION DECLARATION
1 hereby affirm under penally of perjury one of [be following declaration.:
\
have and will maintain. Cenlfteamef Consent to saff- nm. for Worker•,Cmnpen-
orlon, u provided for by Section 3700 of the Labor Code, for Ne pedermnme of the
work for which this permit is issued.
D 1 Mw and will maintain Worker's Compensation Insurance, u mquirod by Section
3700 of the tabor Cade, In, who performance of the weak for which this permit Is issued.
My Workers Compensation Insurea Wrier and Policy number Am:
Carder: Jg4Je✓'%iG T11 Policy No.A=OeCL'L� .%a9
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(fits section need not becomplered Irwin permit I. forma hundreddollAn ($10()
or leu.)
1 Certify Nat in the performance of the work for which this Permit is luucd, I shall not
employ any person In any manner an As to become subject In the Workers' Compensation
Lew. of California Date
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
become subject in the Worker's Compensation provisions of the LAW, Code, you must
forthwith comply with such Provisions or this Permit hall be deemed revoked.
CONSTRUCTION LENDING AGENCY
1 Wreby affirm gut them is a cwmtmnion lending agency for the performance of
Ne work for which this permit Is issued (Sec. 3097, Co. C.)
Lender, Name
I<Merk Adems
1 1 certify that 1 hew read this application and Use that the above wrormatlun I.
COLLI 1 agree 10 comply with all city and county oMnancesand out lam relating an
Wilding construction. and hereby authorize repmsem,tivcs of this city to enter upon the
( ,bove-mentioned properly for inspection purposes.
(We) Allow to have, indemnify and keep harmless the City of Cupertino against
i IwbJHIws jdgmenu. costs And expenses which may In any way&cc= against aid City
WCOMII APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
����
Ito Stgturn of APPllca 0 Doctor � Dow
HAZARDOUS MATERIALS DISCLOSURE
WIII the applicant or future Wilding occupant am or MMI* houdous material
As defined by the Cupertino Municipal Code. Chapter 9.12, ens the Health and Safety
Code, Secdon 25532417
Ne
All roofs shall be inspected prior to any roofing material being installed,
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or (mum Wilding Occupant use equipment at Jcvices which
It Immune, air contaminants u dcbned by the Bay Am& Air Quality Managcmcm
all new materials for inspection.
lalrid7
❑Yes
1 have mad the herald &I, requiremen, under Chapter 6.95 of the Califor.
nla Heal 6 SalclyCodc. Sections 25505,25533 and 25534.1 underuuud that If gra Wilding
due. not Currently hew a tenant. that it is my reaponswilb, 10 nogl'y the eccupant of the
mquimmena which must he mel poor it) issuance or a Certificate of Occupancy.
Signature Of Applicant Date
AP g y. I Cog
All roof coverings to be Class "B" or better
Owner or .utbori dagent Date