04090202CITY OF CUPERTINO
� � ,1.�T 6
1V,$ 1� 1
BmI mNc DIVISIONPERMIT
�, .. ,
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N0.04090202
OWNER'S NAME:
PERMIT ISSUE DATE
SANITARY 146. O OL NO.
ARCHITECrIENGINEER:
BUILDING PERMIT INFO
BLDG ELELT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hcrcby of on (hat I am licensed under provisions of Chapter 9 (commencing
with Section TOO)) of Division 3 of Ne Business and Profeulons Code, and my license is
inrut] (ora and astral. $380g'/&
Lkenm Clu Lte. N
NEW CONDO -1087 SQ. FT.
_df` CusumOur I A (Sq
ARC r1ECrS DECLARATION
I understand my planashell uPublic record,
Licensed Professional
OWNER• ER DECLARATION
I hereby affirm that 1 a exempt from the Contractors License Law for the
fallowing reason. (Section 703 1.5, Business and Projections Code: Any city Cr county
which requires a permit to ennstrocl, titer, Improve, demnllsh, or repair any structure
prior m its issuance. aim requires ik applicant retouch permit to Ole a signed statement
License LOW 9
Sq. Ft. Floor Area
Valuation
that he Is licensed pursuant to the provisions of the Comramr4 (Chapter
(commcodng with Section 7000) of Division 3 of thc Busincu and Propositions Code) or
that he Is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a polish mbjecu she Applicant o a civil Knotty of
not mom than five hundred dollen (8500).
❑ 1, As owner of the properly, or my employees with wages as their Ole compensation,
31620084.00 Required Inspections
will do site work. and lbesuucture 4 not intended oroRemd knale(Sm. 7044,Buiness
License Law not apply m an owner of
and Professore mM1 Code: The ConvOLicensladoes
q P
property who bu Ilds or improves Hereon, and who does such work hl msel f m throujh his
own employees, provldad that such Improwments are not Intended aro@rM forsale. If.
however, He building or Improwment B mid within one eur ofcomphdoe. the owner.
builder will haw the burden of proving Nat he did nm build or Improv fu pulp. of
sok.L
❑ 1, as owner of de properly, am exclusively countering with licensed conn ctun to
construct the project sec. 7044, Business and professions Code:) The Common's U.
cove Law does not apply to an mover of property who W IWI or fmprows therann, and.
who contracts for such projects with • contract.,O licensed pursuant to He Convectors
License taw.
❑ 1amescmplunder Sec. ,B&PCfortismason
Owoer Dow
WORKER'S COMPENSATION DECLARATION
I hereby afflne under penalty of perjury one of the following declarat rune.
eve and will maintain a Cerllacue of Consent to ml6lnmm for Worker's Compen.
Aen, u provided for by Section 3700 of the Labor Cock. for the performance of tha
work for which this permit is Issued.
❑ I haw and will mdnlaln Warker's Compensation Insurance, as required by Section
37M of the Labor Code, for the performance of she work for which Nis permit Is load.
My Workers Compensation Insurance artier and Policy number arc:
_
Cartier. 111/QTt J:'e Tis. CPollry No.: GR[tog�o2!T $9
CERTIFICATE OF EXEMPTION FROM WORKERS'
,
COMPENSATION INSURANCE
(This maim need not Mcompleed If the Permit 4 for one hundred dollen (first
or
1 cenify that in the performance of the work for which this Permit Or issued. I shall not
employ any polOn in any manvrm As m become subject to the Wormso Corepensalian
Laws of California. Dae
Applicant
NOTICE TO APPLICANT:If. after making this Certificate of Exemption. you should
hecmne subject m the we*"-. Compensation pmv4lau of site LAW, CMC, you muss
forthwith comply with such provlsinns m ulu. permit Mdl k dams rewaked.
CONSTRUCTION LENDING AGENCY
len ding agency for Ne per(ormmce of
1herebyaffvm that them11i 4sed
Soc.30
' the wash for which this permit is lured (Su. 3097, Ci, C.1
LandersName
Landers Addnaere,a
i 1 cenify that I haw read this Application and wee that Ne ekw Infmmatrun Is
' colonel. I agree m comply with dl city ad county onfinances and suns laws relating 10
Wilding construction. and hereby authodm representatives of Nis city to enter upon the
show -mentioned property (or inspection purposes.
(We) agree re saw, Indemnify and keep harmless the City of Cupcnino all
i liabilities. judgments, costa and expenses which may In any way aceruC against aid City
In APPLICAuence of the NTranting of his I
ANTUNDERSTANDS ANWILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Type of Roof
• -2/'—Re-roofs
Signature of ApplimaXtolinamor Dow
HAZARDOUS MATERIALS DISCLOSURE
Will He applicant or future building occupant store or handle haardous maerid
a dented by 0e Cupertino Municipal Code, Chapter 9.13, and the Health and Safely
Code, Section 255320t)'I
❑Yes du
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building acupant use equipment or devices which
hauninns sir contaminants As darned by Ik Bay Area Air Quality Management
all new materials for inspection.
4
❑Yea
I have read the haardou maenalt mquionmenu under Chapter 6.93 of site Califon
Tia Hal" Safety Cade. Secdcas 25505.35533 and 25534.1 vodcess nd that If Ne Wilding
does mi currently haw a means, that It 4 my MOOMAINllly m mdfY thC Cecupanl of IM
mqulrcmcnuw' Ise met pnormivame car, CeniMak or Qcupancy.
—Signature of Applicant Date
`
All roof coverings to be Class "B" or better
Own er car mann Date