04090193�d
Y OF CUPERTINO
BUILDING DIVISION PER
"
NG ADDRESS;
PALISADE BUILDERS INC
PERMIT NO.
04090193
' 0AMFTRVB?iSeRIE
;ARCHITECTIENOINEER:
PERMITISSUEDATE
SANITARY ROLNO.
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
p LICENSED CONTRACTOR'S DECLARATION
Job Description
I hereby IMM that I am licensed under provisions of Chapter 9 (commencing
with Section 70111)) of Division 7 of the Business and Profusion, Code, and my license is
in full force and effect R 1' DS .
3 Lmemoclua $—Llo.a
NEW CONDO -1502 SQ. FT.
Dale �-{' !— Co"A"d ON
ARCHITI SDECLARATION
1 undcnnnd m tons. be --.-,.-
Licensed Professional
-BUILDER DECLARATION
License Law for the
1 hereby amen, that 11. exempt from Ne Conions
Co
9 following (Section 7(1)16, Business and Profession, Code: Any city or county
which s permit re ears, eller, Impntve, demolish or repair any structure
wires a
Permit t signed statement
lheuppss.rant forsoch Permit Limafile a
its lu 11m
prior suits iensedpalwntto
Sq. F[. Floor Area
Valuation
.
to the pmvlainnauf the eBusi uhLlProfssio (Chapter
the
<that heucing, with Section r the Business and Profusions Crede) of
Semlon 7Md
egad Any of
he Is emmpt MereDnm end the but, for Ibe alleged exemption,
.. MAI he Is exempt the b t, f the
ApN Number Occupancy Type
pliantto l Penson
Sec 70716 by any for s permit subjects the Applicant a civil Penalty of
red doll
not mem Then Eve hundred tlollan ($500).
not
0 I, As owner cribs proper, or my employes with wages as their sale compensation,
will dothe work, and Me structure is aminunded mof(ered fonsle(Sm. 7044, Business
and Professions Code: The Connotes Llmnsh Lew it= not apply to in owner of
31620084.00 Required Inspections
q p
property who builds or i m proves thereon, end who does such work himself or through his
own employes, provided that such improvementsom not Intended oroQered formic. If.
however, Me, building or improvement Is sold within one yea of completion, the "Act -
builder will Mm the burden of proving that he did not build or improve for purpose of
Asia,).
0 1, as owner of the prepeny, am exclusively contracting with, )landed comnnon to
conmvm the project (Sac. 7004, Business and Professions Cotler) The Contractor's U.
mass law does not apply To an owner of proPony who Wilde or improwa Hereon, and ,
who contracts for such projects with a conlrmtor(O licensed pursuant TO Me CanuAstofs
License Law.
0 1 am exempt under See. . B sit P C for this rwon
Owner Dau
WORKER'S COMPENSATION DECLARATION
I bercby alRrm under penalty of Perjury one of the following declarations:
hem and will maintain a Cemfuase of Concent to self-in,uro for WorkersCompen.
.d... As provided for by Section 37M of the Labor Code, for Me performance of the
work for which Mi. Permit is iamed.
0 1 hove and will maintain Worker's Compensetlon Insurance, As required by Section
37M of the labor Code, for Me performance of the work for which this permit is IAsUW.
My Workers Compensation Imunme carrier and Policy number arc:
carder: atl eelJ`9�B7C Policy No.: �Dbn6�aJ
.
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This Mellon reorient becomplued Hthe permlt Is fmoe hundrecidolim (SIM)
or leas.)
I comfy that In the performanc.. I the work for which this pormit is Issued. I shall 0111
employ any person In any manner sat As In become subject to the Workcri Compensation
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: If. after making Md. Certificate of Exemption. you should
become subject to the Worker's Compensation provisions of [be Labor Code, you must
forthwith comply with such provisions tar this permWhall be decreed ranked.
O
CONSTRUCTION LENDING AGENCY
I hereby affirm that there its construction lending agency for the Performance of
the work for which this permit is issued (Sec. 3097, Co. C.)
Gi Lender's No.
,
z Lender'sAddress
Q 1 unify that 1 have read this application and stale that the shove Information Is
!+ corten. 1 agate to comply with all dry and county ominmtts and Bleu Issas rohting atrU"
buildug construction. and hereby authorize mpresenteliw of this city in enter upon the
W ahove-mentioned property for inspection Purposes.
(We) agree to save, indemnify And keep hamlleu the City of Cupertino agajnsl
yliabilities, judgments, costs and expenses which may In any way scene against Mid City
in consequence of the graming of This permit,
APPLICANT UNDERSTANDS ND WILL COMP 41- U--NON-POINT
Issued by: Date
SOURCE REGULATIONg./�
�// 4/'.2f'e—'Re-roofs
Signature Ol'Ap'li.0117C.10,15T Dole
HAZA SMATERIALSDISCLOSURE
Type of Roof
Will the applicant or future building occupant nate or handle haurdous material
As defined by the Cupertino Mu I I 1 Code, Chapter 9.11. and the Health and Sorely
Code, SGdon 25532(4)7
All roofs shall be inspected prior to any roofing material being installed.
❑ YG
If a roof is installed without first obtaining an inspection, I agree to remove
Will the ftsdolat of ulum building occupant use equipment at dcvims which
I haxardous air contaminants As defined by the Bay Arca Air Quality Management
all new materials for inspection.
iatricli
❑ YG
I have mad the hnamesmaurlsls uquircr ante under Chapur6.95 of the Califon
nia Health ,& Safely Coda, Sce6ons25505,25533 and25534.1 undcntstW door lfthe [wilding
rima not currently have a Mount, that it is my respoeihlllly to notify the occupml Of Me
requimmes which must be l Pour m Issuance of a Cerdncaw of Occupancy.
Signature Of Applicant Date
.2;i
All roof coverings to be Class "Bo or better
ower or unhmry a Date