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BUILDING DIVISION PERMIT
BUILDING ADDRESS;
PERMIT NO.
PALISADE BUILDERS INC
04090196
empAgo
PERMITISSUEDATE
1,659)'79
SANITARY OL NO.
ARCHITECT/ENGINEER:
4:790
BUILDING PERMIT INFO
BLS ELECT PLO MECH
O
LICENSED CONTRACTOR'S DECLARATION
lob Description
p
I hereby affirm that I am licensed under provisions of Chapter 9 (commencing
with Section 70(X1) of Division 3 of the Business and Professions Code, and my licence is
in full form
rte and effect. p LIc.N 8����
NEW CONDO -15.02 SQ. FT
Dam af�Comr.ror GIsAer -
ARCHITECTS DECLARATION
_
1 understand my plans a ed public '
Licensed PRessiona1
OWNE - UILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Lew for the
following mason. (Section 703 1.3, Business and Pndession$ Code: Any city or county
which requires a permit to construct. alter, improve, demolish, m upon any structure
prior to its Issuance, also requires the applicant for such permit to file a signed Statement
die Connectors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is lictrowd pursuant 1. the provisions of
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
Nu he is m¢mpi therefrom and the but, for the alleged eaempllon. Any violadon of
APN Number
Occup ncy pe
Section 7031.5 by any appllunl for a permit subjects the applicant to • civil penalty of
not more Nan R. hundred dollars (SSW).
❑ 1, u owner of the property, m my employe" with wage, u drain rale compensation,
31620084.00 Required Inspections
wllldo the work, and the structure 1, not Intended m offered foraale(Sec.7044,Bmirou
and Professions Code: The Communes Lim es Law docs not apply to an owner of
q1
property who builds or imparm thereon, and who does such work htmolf"through his
own employees. provided thatauch improvements ,re rminlended oroaered forest*. if.
however, Ne building or Improvement is sold within one year of compleaion, the owner.
builder wig have the burden of proving Nu he did not build m Improve for purpose of
W.J.
❑ 1, as owner of Me property, am exclusively contracting with licensed member, to
construct the Fatima Dec. 7044. Business and Profusions Code:) The Cont"oror'. Li-
cense Law does not apply to an owner of property who builds or improves the.on, and
-
who contracts for such projects with aronvmmr(q licensad pmrmmt m die Comramor's
Lken. Law.
❑ I am exempt under Sec. ,B@P C for this means
Owner Date
WORKER'S COMPENSATION DECLARATION
1 hereby offnm under penalty of perjury one of the following decimations:
ave and will maintain a CeniOnte of Consents. salf-Inure for WorkeM1Compen-
nlon, As pmvided for by Section 3700 of Ne labor Code. for the performance of the
Wfor which this permit is issued.
❑ 1 have and will maintain Workels Compensation Warsaw, u required by Sermon
3700 of Ne Labor Cade. for the pertormance of Ne work (or which was permit Is Issued,
My Wallace, Compensation Insurance "vier and Policy number am:
Cartier: AATn74' 1^tAl Palley No.:11��n�'
—�
CERTIFICATE OF EXEMP71ON FROM WORKERS'
COMPENSATION INSURANCE
(nds section need not hecorepleted lithe Permit Isforonc hundred dollma ($1(1(1)
or less.)
I certify Nal In the performm. of the work for which this permit Is issued, I Mall not
employ any person in any member an u m become object to the Workers'Compensadon
Uvea of Cdifomla. Dote
Applimant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption, you should
become subject ro the Worker's Compensation provisions of Ne Labor Code, you must
forthwith comply with such provisions or this permit shall M deemed rcvnked.
CONSTRUCTION LENDING AGENCY
I hereby aRrm Net Ne.tsa agency for performance of
the work for which Ms permit B isaued ISec. 31197. Co.Civ. CJ
issued (Sec.
Nemo
Under'" Address
1 certify Net 1 have read this application and sum that the also. Information is
l agree to comply with all city and county ordinances and state laws relating to
building conawnion, and hereby amhore reprersenlnivice of this city to enter upon tM
above-mentioned property for inspection purposes.
(We) agree to saw, indemnify and keep harmless the City of Cupertino Against
Ilabilide,, judgmenu, coats and expense. which may in any way accrue against sold City
in consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:3 Date
SOURCE REGULATIONS,
-roofs
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Sig.vera fApplamWoodoll Dam
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant W future building occupmlato. m handle ha"rdous muralist
As defined by the Caperton Municipal Code, Chapter 9.12, and the Health and Safmy
Code. Secdon25532(a7/
All roofs shall be inspected prior to any roofing material being installed.
(-]YetSENO
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
haxardnus all contaminants As defined by the Be, Arca All Quality Munsemu nt
all new materials for inspection.
strict?
❑ Y..
I have mW the hmardous materials requirements underchap er 6.95 of the Califor.
ala Hea m A SafctyCode, Sections 25505,25533 and 25534.1 understand Nat lithe Wilding
does not currently haw a tensm, Nn It Is my mspoutMlity m nod ly the Wammen of the
requirements which must Imumsol poor to Issuance of. Deain"te of Occupancy
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner rrwith aomdagam Dm42
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