04090173Y OF CUPERTINO
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BUILDING DIVISION PERMIT
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ING ADDRESS:
PALISADE BUILDERS INC
PERMITNO. 04090173
R'S NAME:
;ARCHITECTIENGINEER:
PERMTTL55UBDA7E
E:
SANITARY N OL NO.
BUILDING PERMIT INFO
BILDO ELECT PLUMB MEECH
O O O O
LICENSED CONTRACTOR'S DECLARATION
OeBGrIP
Job Description
1 krohy effort real I am licensed under provisions of Chapter 9 (commencing
with Salton TOM) of Division 5 of la Business and Profculna Code, and my license is
"n"forte end effect.
Lkena Glasse Lk.g �4�6
NEW CONDO -1102 SQ. FT.
_ Cuntoaca
Oem r .SAOm
ARCHITECrS DECLARATION
I undma nd my tlanuhall k use uWwwee --
Licensed Professional
OWN .R -BUILDER DECLARATION
I arcby .Them That a.1. exempt from the Crinins License La. far the
Co
following wood. 71131.5,Buamsaand Professions Code:Any city Or county
which requires • permit re cnmwat alter. Improve, demolish, or minorealag any structure
ceroid
prior ba.sl Iuumro,realso rcqu peak applicant for each Glcs Law
Contractor's License law
Sq. Ft. Floor Area
Valuation
rcrmiuo
that the is licensed punuemmthe pmvlelnna of the (Chaper9
(commencing with Section 7000) of Division 3 of the Butincaeand Profeulnns CnJe) or
that he is exempt th,mfmm and On basis for Ne alleged exemption. Any violation of
-67
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit Objects the applicant s civil penally Of
am marc than fiw hundred dollars (1500).
❑ I, as owner of the prepeny, or my employees with wages u their ale compemallon,
31620084.00 Required Inspections
will do the work, andthtinclum is not intended or offered fonele(Sec. 7011, Business
n
and Professions Cade: The Connector's License Law donot apply a an owner of
q P
property who builds or impeows Nercon, and who does wch work hi malf or through his
own employ=. provided that such Improvements arc not Intended aro@ped feature. if,
however. Ik building or Improvement Is mid within am year of completion. Ne owner.
Wilder will have the burden of proving that he did rot build of Improve fm purpose of
ase.).
❑ 1, as owner of On, property, am exclusively cantrac ul with Ilceued commcan to
construct the project (Bee. 70th, Business and Pmfeasiaus Code:) The ConOecar'a Li-
cense law docs not apply a an owner of properly who builds or Improve, Owner. W ,
who contracts for such projecs with r comnctor(s) licensed parallel m the Contractors
License Law.
❑ lam exempt under See . B R P C fm rule seam,
Owner Dam
WORKERS COMPENSATION DECLARATION
I homey affirm under penally of perjury arc of On following dcelmtroa:
Mw and will maintain a Cmdfinn of Co..[ to self-imuee for Wmkcfs Coupon.
:lion, u provided for by Section 3700 of the labor Code, for the performance of use
work for which this permit is issued.
❑ 1 haw and will maintain Worker's Compensation Insurance, as required by Sudan
"To or Nclaar Cude,for else performrme of Ne work fm which Nis Permit is wmd.
My Workers Compensation Insurance carrier and Polity number am:
Currier. ISIAJ.bi9f zlx Cr Polley No.: O
CERTIFICATE OF EXEMPTION FROM WORKERS'
,
COMPENSATION INSURANCE
(TMs mcMn need nothecompleted little permit ls forma, hundred dollars (Sim)
or Ica.)
I ttnify that In the performance of the work for which this Permit Is issued. I shall not
employ any person in any manner in as In became subject to that Workers'Compenullnn
Lawes of California. Dam
Applicant
NOTICE TO APPLICANT. If, after making this Cenllicam of Exemption, you should
became abject to the Worker's Compemulon provisions of the labor Code, you must
Forthwith comply with such provisions or this permit aNll k deemed nevaked.
CONSTRUCTION LENDING AGENCY
1 hereby aBlrm that JCn it a comlNedaa lending till for Ik Performance of
thc work for which this permit LL leaned (sec. 3097, Civ. Ca
Lender. Name
Lmmerti Addreas
1 ttnify that I haw reed this application end mob that the wave Information IS
correct. 1 a&= to comply with all city and county On imnnnnd awe laws mining to
building construction, and hereby avthurim Mpreaeutivea of this city to enter upon tiro
rave-reema ned property for inspection Purpose..
(We) agree to taw. indemnify and keep humieas tk City of Cupcnhm against
j liabilities judgmens, corn and expenses which my in my way same spimt slid City
In conagmme of the gMdeg of this permit.
APPLICANT UNDERSTANDS AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
'Type of Roof
'a'Il
Signature ol'Applicanl/Camr °i"
HAZAR LS US MATERIADISCLOSURE
Will Lou applicant sir future building Occupant nope or handle haasedous, material
as dented by the Cupenlno Municipal Cade. Chapter 9.13, and the Health ad Safely
Cade. SwOm 35533(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes X.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
banal air contaminants as dented by the Bry Arca Air Quality Management
all new materials for Inspection.
nicl7
❑ Ye.
I he,. raid the hauaeaus materials requamenla under Chapter 6.95 of the Celifor.
nla Hal tit SafetyCode. Sections 35515,25533 and 35534, 1 umisoand that If to building
does not currently how a tenant. that It 1, my responalhility a naNy tk ocCowel Of Jm
mgmremens which rosin met arml cgnrgccNneamaf Oa Panty.
Signature of Applicant Date
All roof coverings to be Class "B" or better
ownae t arivcde m Dam