04090169U
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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.
04090169
A-AA;A:Tr.VENbPERMIT
ISSUE DATE
SANITARY0J'20/2 OL NO.
ARCHiTECTIENGINEER;
BUILDING PERMIT INFO
BLDG ELECT PLO
O O
LICENSED CONTRACTOR'S DECLARATION
lob Description
I hereby affirm Nu 1 un Revised under Provisions of Chapter 9 (commencing
wish Section 7") of Division J oft the Business and Pmfculum Code, and my he... a
in full force and effect.
Limn e Cl Lk.g •g O
NEW CONDO -1102 SQ. FT.
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Dau -6 Camra^o!3`�5'��^_ n•nw�s
ARCNIT[LTS DECIdRATION
IundcnunJm I uatlkued klienecmFdg-
Leensed Profcuionai
O NER.BUILDERDECLARATION
I hereby efarm that I em exempt from the Contractor's License Law for IM
following mason. (Section 7031.5, Business and Pmfeulons Code: Any city or wunty
which requires a Permit to construct. ager, improve, demolish, or repair my structure
prior Io is iuumm' also requires he applicant forsuch Pereelt to ale a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant in the provisions of the Contractor', Leman: Law (Chapter 9
(mom mincing with Section 7000) of Division 7 of the Business and Profculm, Code) or
that he u exempt therefrom and the boa for On alleged exemption. Any W.duo of
APN Number
Occupancy Type
Section 7071.5 by any appllcmt for a permit ubjects the applicant in a civil penalty of
not more Nan five hundred dollars (5300).
❑ I, As owner of the property, or my employees with"Sea u their ole compensation,
31620084.00 Required Inspections
will do the work, and the aWc9ure is not intended or offend for sale (Sm. 7041. Business
And Pmf.uions Code: The Contractor's Lt.= law due, not apply toe an owner of
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property who builds or Impme gthereon,and who doesouchwork himselforthrough his
own employees, provided that such improvemenuare not Intended or offered for We. Jr.
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
tel..).
Ej 1. as owner of Ne property, am exclusively contracting with licensed contractors to
consumer the project (SCC. 7044, Business and Profelalons Code:) The Contractors LL
cense taw does not apply to an owner of property who build, or Improves Hereon. and,
who contracts for such project, with a conuactor(t) licensed pursuant to the Contractors
Leen. Law.
❑ 1 am exempt under See. . B & P C for this resson
Owner Dau
- WORKER'S COMPENSTIONDECLARATION
1 hereby &from under penalty of perjury one of the following declarations:
1 have and will maimed. •Cmifinte of Consent to el6lnure for WorlCompen-
ution, ss provided for by Section 7700 of dk labor Code, for the performance of the
work for which this Permit Is issued.
❑ 1 haw and will maintain Workers Compensation Insurance, u required by Section
3700 of the Labor Code. for Use, performance of Ona wok for which this permit is Issued.
My Workers Compensation Insurance artier and Policy number are:
Caller. MFIJC57 C 7%< Pohcy Node Oe ,2 ab
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Thisectioo need rot be completed If de permit is fooue bundrad dollua(SIe)
mess.)
I certify Net In the Prfnrmaece of the work for which this Permit is Issued. I shall not
employ any person in any summer so u to become subject o the Workers Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT, If. after making His Cenlacatc of E&emPldon, you should
become subject ro the Worker's Compensation provisions of the laho Code, you must
forthwith comply with such provisions or this Permit hall he deemed rooked.
CONSTRUCTION LENDING AGENCY
I hereby alarm Nu share i, a construction lending agency for the perfocrmm of
He work for which this permit 1. issued (See. 3097, Civ, Cd
LCndera Name
Lender's Address
I certify that 1 haw read this application and gain that the shove Informatlon is
correct. 1 agree H comply with all city and county ordinances and sal, law relating H
building convection, and hereby authorise representatives of Nit city to enter upon the
above-meniiuned property for inspection purposes.
(We) ague to sive,gainst indemnify and keep harmless the City of Cupertino A
-
j Iiablli0e1,judgment,, costs and expenses which may In any way mcne against aid City
In consequence of the gsaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE RPAULATI
Re -roofs
Signature of Applicam/Con 'w Dote
HAZ OUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding =upon, more or handle huallous material
defined by the Cupertino Municipal Code, Chapter 9.17, and the Hcalth and Safety
Asldto-
de. Section 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑ ws
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devises which
It haumnue air contaminants u JeOmd by the Bay Amo Air Quality Mansgemem
all new materials for inspection.
utcn7
❑Yea
I have read the hanrdmu makrlafa myonerecou under Chapter 6.93 of the Califo-
ulH & SefnyCodc. Sections 25515.35533 soul 25334.1 a nk guud tial lite with.,
Out wrongly haw a ammt, Our h a my re,pomlMlily to notify the oodupmt of Nt
uinmenu which mum be mel psi0 auaoe of a Cerifkal, of Occupancy.
Signature of Applicant Date
,It-OAll
roof coverings to be Class "B" or better
ner 9r suthod'ed sge Dau