04090182�09F
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CITYOFCUPERTINO
BUILDING DIVISION PERMIT'GUITRA
BUILDING ADDRESS:
PERMIT NO.
PALISADE BUILDERS INC
04090182
O E 5 ME:
PERMUISSUEDATE
SANITARY N 4/2 L NO.
ARCH17ECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECTO PLUMB MECH
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
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I thereby affirm that I un licensed under provisions of Chapter 9 (commencing
with Smile. 7000) of Division 3 of the Box. and Professions Code. and my license is
in full fora and offal. gaB�L
LkemcClaae uc.R -
NEW CONDO -1104 SQ FT
Dale 0�' Customer AC: f�D.d
ARCHITECTS DECLARATION
1 momm and my Plans shall se . Pu asnsd
L'ucnsed _PmformormilOWNER-BUIV
EECLARATION
I hereby affirm that I am exempt from dm Contractor's License Law for i W
follmving mason. (Salon 7031.3. Business and professions Code: Any city or county
Which popires • permit a eanmruct, Nur. Improve, demolish. or repair any anmture
prior m its issuance, also reporter [be applicant for such Permit m file asigned statement
Sq. Ft. Floor Area
Valuation
War he in licensed Plmaamro m, provWons of the Comruror'. Llene Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
mat he is exempt therehum and me basis fa sin alleged caemPtlon. Any violation of
APN Number
Occup, Cy pe
Section 7031.5 by any applicant for a permit objects the applicant to a civil penalty of
not mare dun five hundred dollars (5500).
❑ 1, As owner ofthe Property,"my employe" with wagem their sole Compensation.
31620084.00 Required Inspections
e
will do the work, and the structure is not mmndedm offered forsde(See. 7044. Business
end Formation, Code: The Connector's License law does Trot apply m an owner of
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properly who bullda m Improves Mercer, and who da"uch work himselfor through his
man employees, provided that such Improvements Are am Intended oroRemd (male. if.
however, the building or Improvement Is mid within one year of completion, the owner.
Wilder will have the burden of proving that he did not Wild or Improve for purpose of
ark.).
❑ I, as owner of the property, am exclusively contesting with licensed Contractors to
construct the projem (Sec. 7044, Business and Profmamrs Code:) The Contractor'. Ll-
6cane
cametaw docs not apply to an owner of property who Wild. or Improve, thereon, and
who common for such projects with a contractor(,) II"rad pursuant o the Contra mem
License Law.
❑ 1 am exempt under Sec. B k P C for this Came
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penally or perjurysum or the following declarul...
hie and wlli maintain a Certificate of Ccnem to elhiMum for Workees Compen.
mion, u prmidW for by Section 3700 of the Labor Code, fm me performance of the
work for which sob permit I, issued,
❑ 1 have and will maintain Worker's Compensation Insurance, u required by Section
3700 of the Labor Cade, for de perfornm me or the work for which this result Is Issued.
My Workers Compensation Inmm=carticr and Policy number art:
Carder: 0040.2<y7k 1 k-CPolicy No.:t2OV45v2SJ' n
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becmopleed If floc permit D for one hundred dollars($100)
or I"n)
1 certify that In the performance of the work for which this Permit is issued, I .hail not
employ anypcmn in any summer an as in become subject to the Workcn' Compensallm,
Laws of CW fomm. Dau
ANAICIAl
NOTICE TO APPUCANT: If. afar making this Certificate of Exemption, you mould
become subject in the Worker'. Compensation provisions of the Labor Code, you mum
forthwith Comply with two provisions or this permit mail W deemed mmked.
CONS. ON LENDING AGENCY
1 hcmhythi Mudue is t omm incnry for IM Pesfmmame of
is a o Utinn lendg ag
w IMt permit Is lured (See. 309'1. Civ. C.)
' the oo fa which
Lenders Nares
'
lender's Address
1 1 minify that I have road this application and sure that me above Informatlim is
correct. l gree to comply with all city and county ordimmod, and IUM law elating m
building construction. and hereby mmades mPr"ematives of this city to enter upon be
i above-mendarrod property for impaction purposes.
(We) agree to eve, Indemnify and keep harmless the City of Cupertino against
I Imbilides,judgments, amts and expenses which may In any wary seem" against aid City
1 in consegmncc of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:3 Date
SOURCE REGULATIONS.
�4/'1 'l'y
Re-roofs
Type of Roof
Signuurc ofApplicartiConormourDau
MATERIALS
HAZARDOU5 DISCLOSURE
WIII the applicant or future building occupant more or handle haarduu. material
As defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Codc,Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes No
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future ilmng occupant use equipment or devices which
t haardousser contaminants ss deftncd by the Bay Arta Air Quality Management
all new materials for inspection.
District?
Yes f�
I have mW the hnadma materials requimsucnu under Chap er6.95 of the Celifor.
M4 Health k Safety Code, Smtiom25505, M533 and 25534.1 understand thulfthe building
Mmnot currently have a unset, that it Is my uaponsihlllly ro ratify IW mcuPanl of the
myulremenu which must WMCI poor u nue, or ceAnese ser OcmPaney,
i nature of Applicant Date
,pal
All roof coverings to be Class "B" or better
Owner or emhmizcd agent
C