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CITY OF CUPERTINO
obryl�FORMATiq '
BUILDING DIVISION PERMIT
CONTIt.
BUILDING ADDRESS:
PALISADE BUILDERS INC
PEKMITNOh4090165
kmNAmP.TEVENS
PERMIT ISSUE DATE
�p RGUSING PARTNERS
T61BID909 ALMA S-111,
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SANITARY 0. CNTROL NO.
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
o
LICENSED CONTRACTOR'S DECLARATION
lob Description
P
1 Wnby affirm that l am Ilcenaed under provision. of Chapter 9 w0noomming
with Sudan 70(X) of Divinlon 3 of No Businueand Prouulons Code, and my license is
In fu11(am and effect. n
LlcenO CW! Lic.as 4t2gat-
,NEW CONDO -1102 SQ. FT.
Dam contractorSAdfC orb.
i
ARCHITECTS DECLARATION
1 undenun m Ouhatl W u¢ ie rtrnr�`
Licensed Profesaleast
OWNER.BUILDER DECLARATION
I bcamy Balm that I em exempt from the Contractors Limnse Lew for the
following women. (Schon 7031.3. Business and Profcuinas Code: Any city Or Courtly
which aquina a permit to mnavuct, alter. Improve, demnl W. our repair any nronun
prior in its issuance. else requires the applicant for such permit to file • signed allotment
COnlra:hn'a Lima. Le. (Chapter 9
Sq. Ft. Floor Area
Valuation
that he la licensed pursuant In We pro,wwara of the
(commencing with Section 7000) of Division 3 of the Business and Pmfcaswns Cede) or
that be is exempt thwofrom and the beau 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
not more than five hundred della. ($500).
❑ 1. no owner of the property, or my employees with wage as their Ole Compensation,
. Required Inspections
will do the wart, and thesWclurt la not Intended or offend tweak (Sec. 7044, Eastman,3162008400
Code: The Consomme, License law does not apply an owner of
and Prefeeaians m
9 P
property who build, or Imphaves thereon, end who dmuuch work himself or through his
own employees. provided Nesmith Improvements are not Intended oroffered (wale. It.
however. Ne building or improvement is Old within one year of completion, the owner.
builder will have be burdO of proving that W did not Wild an Improve (w purpose of
ale.).
❑ 1, as owner of tite progeny am eaclusivsly contracting with licensed Cenuacmn to
Construct the project (See. 7044, Business and Professions Code:) The Conoatw't L4
nae law does not apply to an owner of property who Wilds or Improve, thenen, and
who contracts for such pmjceu with a eommular(s) licensed pu.uam to the Contractor's
License Law.
❑ lam exempt under See. ,B A PC for this reason
Ower Dau
WORKERS COMPENSATION DECLARATION
1 hereby &Man under penally of perjury am of IW following dederallmr:
lure for Wwkees Compere
I have and will maintain a Cenifino of Covent to xe6lns
radon, u provided for by Section 3700 of the labor Code, for the performance of rhe
wort for which this permit is iutud.
❑ 1 have end will maintain Workers Compensation Insurance, ea required by Section
311 of Ne labor Code. for We performance of the work for which this permit is Issued.
My Werkeee Compensation Immor , carrier and Policy rum am:
Cardtr:/51/Q1r�IiC rYiC Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thisuctlm need not he Completed Ifs c permh ,(wore hundnddollao(SIM)
lir len.)
I certify that In the performance of the work for which this permit is issued, I ,hall not
employ any person In any manneran as to become Object to the Workers' Compensation
U. of California. Dau
Applicant
NOTICE TO APPLICANT. IL after mating Nis Certificate of Exemption, you should
became subject in the Workers Compensation provisions of We Lahw Che, you mml
forthwith comply with such provisions or thin permit shall W deemed revoked.
ON LENDING AGENCY
CONSTRUCTION
Is, construction Clancy for the performance of
1 hereby affirm Nes thmrc b a
(Sm.3lending
the wart fore this permit Is lured (Sm. )091, Civ. C.)
Lenders Name
l
Lender's Address
I certify that 1 haw read this application and sues that the above Information is
came[. I egret to comply with all city Bad county ordinances and Bute laws wilting 10
building conatmclion, and barely authorlm representative, of this city to enter upon the
abmcmenlioned property for inspection purpoug
l (We) agree to now, indemnify Oil trap harmless Its City of Cupertino against
j liabilities, judgments, cuts and expenses which may In my way Beane against Can City
in comeonce of the gaining ofAPPLICANT UNDERSTANDSthis
WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC REGULATIONS.
Re -roofs
Type of Roof
21-0
Signuure o(ApplinnV ntrO r Dau
MATERIALS DISCLOSURE
H RDOUS
Will W applicant an filum building Occupant nom "Mile hazardous mmawl
as defined by the Cupertino Municipal Code. Chapter 9.17. and the Health ad Safety
,Lc. salient 2ss3:(a)7 .
All roofs shall be inspected prior to any roofing material being installed.
❑Yeats
If a roof Is installed without first obtaining an inspection, I agree to remove
WE,, the ePplicanl m/fuwm`bulli ing Occupant use equlpmenl or device, which
IPr It hayArdnus it cmntaminatns as dented by the Bay Area Air Quality Management
all new materials for inspection.
District? /
❑Yca
_
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11 acmW the hararthus materials requimmenu under Chapter 6.95 of The Cali fon
lila Honk Safely Code, Sectims 735113.35533 and 25534, 1 underamod 0wi f the building
Man not currently hew a wmnh Nat Is Is my responsibility in madly the OccupOl of the
requirements which must beaust poorm ininsc ofa CcniOcau of Occupancy.
Signature of Applicant Date
I
All roof coverings to be Class "B" or better
Owner or tush ad agent Date