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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDINGADDRESS:
PALISADE BUILDERS INC
PERMITNO
04090176
A
PERMITESUE DATE
SANITARY D. C OL Nit.
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMBMECH
o I�
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70110) of Division 3 of the Business and Pro(essiou Cude.and my license is
in full forte an0 effect. IpnSR yr{ C,
License Clus Lic.0 a
NEW CONDO -1478 SQ FT'
Data `0�-cmunsetor PN - ra/'
ARCHITECTS DECLARATION
I and crstend my plan. Mll w Bc r
Licensed Professional
OWNER -BUILD DECLARATION
1 hereby affirm that I am exempt from W Contractor's License Lew for Ihe
fallowing mason. (Section 7031.5, Business and Pmfe.alou Code: Any city car only
which reyulm, a permit to construct, altar. Improve, demolish, or repair any Structure
prior At its Issuance, also requires the applicant for such Permit w rile a signed statement
Connecters Ummc Law (Charter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant in the prevision of the
(commencing with Salton 7010) of Division 3 of the Busineuand Profwinm Cade)m
that M 4 exempt uerefro n uM the bass for the alleged exemption. Any violation of
APN Number
OccupaneyType
Section?on.5byanyApplicantfarapemtbanbjeeutheaPPlicanlleacivilPealtyOf
not more than five hundred doled (5500).
❑ I, As owner of the property. or my employees with wages as their sale compensation.
3162008400 Required Inspections
will do the work, and the suuature is not intended ornnczed forsale sec. 7041, Business
r's License law does not apply an owner of
and Pro(eealons Code: The Chamber's
. 9 P
property who builds or I mprowa thereon, and who dauuc lework himse If or through his
own employees, provided than such Improvements arc notlnu sided reoffered forukJr.
however. the building or Improvement is sold within one year of completion, the owner.
builder will Wan the burden of proving that he did not build or Improve fa purpose of
.1. 1.
❑ I, as away of the Property, am exclusively contracting with licensed contruwrs in
construct the project (Sec. 7044. Business and Profeulom Code:) The Cantrsewr'a Ll -
cam, law does not apply in an owner of property who builds or improve thereon. aha
who contracts for such projects with a eom uctoKal licensed pursuant to the Conuaeloes
License Law.
❑ I em excerpt under Sea .B k P C for this rtuon
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby aBlrm under Penalty of perjury one of the following declarations:
I hew end will maintain aCenificato of Cement car scif-usuw for Worker's Compen.
.,ion, As provided for by Section 3700 of the labor Code, for the performance of the
work for which this permit is issued.
❑ 1 haw and will meinuam Woker's Compensation Insurance, as requind by Section
3700 of the labor Code, for the performance of the work fa which this permit is Issued.
My Worker's Compensation Imurame ants and Policy number are:
Cartier. 01103-1;7k 744(- Policy NO.:�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(Th4 section=it net becompleted If the permit is for one hundred dollars ($100)
or less.)
1 certify that In the performance of the work for which this permit Is Issued, I shell not
employ any person in any manner an As In become subject to the Workers Compemminn
Law. of CW fnmla. Data
Applicant
NOTICE TO APPLICANT:If, afler making this Certificate of Exemption. you Nouns
beromta subject to the Worke . Compensation provisions of use labor Code, you mug
forthwith comply with such provisions or this Knink shall be dammed revoked,
CONSTRUCTION LENDING AGENCY
I hereby aRrm Nat Nem is. eomwminn lending agency for The Performance of
she work fm which this permit is issued (Sec. 3097, CO. C.)
Lender's Name
Lender's Addmas
I certify that 1 haw read this application and rote that the abow Information la
cancel, l gree to comply with all city and county ordinances and rule laws relating to
building construction, and hereby authorize representatives or this city to enter upon the
above-mentioned property for Inspection pupates.
We) agree to taw, indemnify and keep harmless be City of Cupertino agalml
j liabilities. Judgments, costs and expenses which may in any way acme agalmluid City
In consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. '
Re -roofs
Type of Roof
Signature of ApplicandCoanutm Dau
HAZARDOUS M ALS DISCLOSURE
WIII the applicant or future building occupant atom in handle haardous material
as dented by the Cupenuo Municipal Code. Chapter 9.11, and the Health and Safety
COJa. Sc 15531(1)?
All roofs shall be inspected prior to any roofing material being installed.
yen .e'
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the a:pliam/or furore\bull�h{ acupant taw eyulpmenl or devices which
It haurdous air contaminants u dcrincd by the Bay AMA Air Quality Management
all new materials for inspection.
atria?
p Yes o
How, rdmumatar44 myulrements unJerCNPur6.95 of the Glifor•
n4H.I"SefmyCode.Sec a=25N15,15533uu1255N.l undenuM Nuifth Wilding
data ret comedy Mw a cant. Net It 4 my rupomihlllty to ratify IM occupant of the
_
requiremrea whichmug metprior or issuance or a Ceatifeale or Occupancy.
Signature of Applicant Date '
All roof coverings to be Class "B" or better
Owner m anthmixed a ant Dam