04090192CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
#CUNTR:A.CTOIi INFORMAT ON'•.
BUILDING ADDRESS:
PALISADE BUILDERS INC
PEaMIT No. 04090192
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY 0 OL NO.
ARCHITEC MNOINEER:
BUILDING PERMIT INFO
BLDG ELECT' PLUMB MECH
o l�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 Mmby afliml that 1 am licensed under provisions of CWpar 9 (commencing
with Section 70110) to Diviaimn 7 of Tho Bualnesund Profcasioni Cadre. and my license is
initial farce and affect,
3
NEW CONDO - 1104 SQ. FT.
LIc.M
L.
Date tl COnrmmf
CHITECrS DECLARATION
I mdosand my pHns.lull be uwdy}uM c mcorda
1��
Licensed
Licenced Fre
Oat
a CmuraON
I thereby I am exempt from Law for the
(Sec that 11. uempe from the Cnnlnnofa
Ons Code: Any city of county
moon . 703 1.5,B. and e: Any c
Improve. de sererepaira urm lume
cermet, alu5 lmpmvu,
permit 1 when,
which myuima • pcgnh
which M
h formals t sig ed
summers, prior minsiarmadp Alan
re tMvFFliem for such Mnniuoftk. signeddmumcm
Lhxnse law
Sq. FL Floor Area
Valuation
Net Kislicensed Furtuanun Ne previsions of the Conuaclor', (ChaFar9
paws.,
(commencing with Section 1000) of Division 7 of the Business and Professions Cade) or
that k is exempt therefrom and the bask far the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7071.5 by any applicant for a permit subjects the applicant to a civil penally Of
not mon Than Bve hundred dollars ($300).
.
❑ I, u owner of the pmpmy, or my employee with wages u their axle mmpenu0an,
1620084.00 Required Inspections
q P
will dothewmk,.nd lheanuclurnisnmintendedoroRered rends(Sec.70M,13udwa
and P.ofesuons Cade: The Contncuw Ys License ladata not apply m an owner of
property who hullds or Improves, thereon, and who does such wok M mal f or through his
own employees, provided that such Improvements of not intended croRued foruk. If.
however, Ne Wilding Or Improvement Is old within arc year of complcdm, Ne names.
Wilder will have [be harden of proving that he did not Wild or Improve for purpose of
,arc.).
(3 1, as Owner of Ne property, am exclusively convicting with licensed mnusemn in
conslracl the project (See. 7044. Business ad preftasiOns Code:) The Conuacmrk LL
cense law does nm apply to as awns, Of property who Wilds or improv themon, And
who contracts for such projects with a ontracmr(s) licensed pursuant se site Conuachn S
License Law.
❑ 1 am exempt under Sm. . B h P C far this Mason
Owner Deu
WORKER'S COMPENSATION DECLARATION
1 hereby Man under penslly of perjury ons of the following declandona:
"
e
om for Workse-Copre
have end will residual. • Comfiest,eu of Couto self-insm
u provided fm by Section 3700 of the labor Code, for Ne performance of the
work for which Ibis Front, Is iuved.
❑ I have and will maintain Worker's Comperue0nn Insurance. u required by Section
771 of Ne labor Cade. for the performance of the work for which this permit is Issued.
My Workees Compensation Insunnee carie and Policy number are:
Cooler. i:4lQvi ST� ry C. policy No.: �3
CERTIFICATE OF MEMPnON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not he completed lithe Permit Is forma hundred dollars ([11)
or las..)
I cagily Net In The performance of [be work fm which this Formal B Issued, I shall not
employ any KMA In any manner an As m became subject to the Walkers' Compceallon
Law, of CW fomla. Dau
Applicant
NOTICE TO APPLICANT: If. after meting this CcniBnu of Exemption, you should
hmmne object to the Worker's Compensation provisions of the lahm Codc, you man
forthwith comply with such provisions or this permit shall he deemed revoked.
Mal Me.UCp10NLENDINOAGENCY
fir Ne p,rfmm.mx of
1hathy.Rthi Wt NetinconIS".3 N.
.O .)
' work far which this permit k issued ISm. 7091. Civ. C.)
Lender'. Name
Le
Lender's Address
1 certify that 1 have read this application and sou that the above Information i,
' ortecl. I agree to comply with all city and county on insmna and ata laws relating to
Wilding construction, and hereby augagan lepreanative, of Ni, city to enter upon the
'
above-mentioned property for inspection purposes
(We) ,gree to save, indemnify And kap harmless, the City of Cupertino a[•Ing
j liabilities, judgmenW costs and expenses which may in any way ace.m against mid City
In i
ANTUN WILL COMPLY WITH ALL NON -POINT
APPLICANT Eof ft RSTANDSoading of IAND
Issued by: Date
SOURCE REGULATIONS,
Re -roofs
Type Of ROOF
Signature of AppImb;VConlnemr Data
HAZARDOUS MATERIALS DISCLOSURE
Will the appikanl ser fuam Wilding occupantrom m h,Mlc huudoes maurial
As defined by the Cupertino Muntdpal Codc. Chapur 9.12, and the Health and Safety
care, Secdm 25532(s)7 ��gl.,
All roofs shall be inspected prior to any roofing material being installed.
13Yes 0
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant m future building occupant ase equipment or devices which
r hse.aou, air contaminants As defined by Ile Bay Ata Air Quality Management
all new materials for inspection. '
u.in7 ` ,
❑Yta
/�Mr
I havercwh thelaarthms m.terl ismqulmmenuunder Chapwr6.95Ofsite Califon
.is Health &Safety Codc, Secuou 255(15.23577 and 25534.1 undcnund thuafthe hallaut
does not currently haw , tenant, that It is my responsibility An noel I'y the mcupanl of the
tyuhmcnu which muss Wmetfe�Aro a,moce afactatificate Olfkopancy
Signature of Applicant Date
sz�� Yet
All roof coverings to be Class "B" or better
Owner or mthmrired. and Det,