04090211CITY OF CUPERTINOa
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BUILDING DIVISION PER
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BUILDING ADDRESS:
PALISADE BUILDERS INC
FBKMIT NO. 04090211
OWNER'S NAME:
PERMITISSUEDATE
E:
SANITARY N 0 iOL NO.
ARCHITECT/ENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
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I hereby affirm Wt I am licensed under provisions of Chapter 9 (commencing
with Section 7000) of Divlalon 3 oflhe Businc"and Professions Code, and my license is
in full force and effect so � j 0 K t0
Litenw Cles tie.«, �•—R�—�
NEW CONDO - 1530 SQ: FT.
On. `m Contractor�eSlq 0r_
ARCHITECTS DECLARATION
'
I understand my plana shell se es pts Ate
Licensed Profcsaional
OW 1 UILDER DECLARATION
I hereby Affirm that I am exempt from the Committee, License Law for the
following mason. (Section 7101.5. Business and Professinu Code: Any city or county
which require, A permit to coMrwL alter, improve, demolish, or repair any strecmre
Prier to its iuuanee, also requlea the applicant forsuch permil to rile a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pmumni to the previsions nfthe Contractor's Liconse Law (Chapter 9
(commencing with Section 7000) M Division 3 of the Businepnd Pmfessiona Code) Or
that he u exempt therefrom and it, bub for tit alleged c"mpdom. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applicant to a civil penalty of
AM mart Nan five hundred dollars ($500).
❑ I, a owner of the properly, or my employee, with wages As their win compensation,
31620084.00 Required Inspections
will do the work, and the structure ianotimmmded mediated Beside (Sec.JUSa, Business
and Prefealon. Code: The Commute, License law doe, not apply he in owner of
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property who bu Ilds or I m proves Hereon, end who dons s uch work himself or through his
own employee, provided thalauch Improvements M not Intended oraBered for,ale. If.
however. the building or improvement is sold within can yeti of eomPletion, the owner
buil&' will have the burden of proving that he did not build or improve for purpose of
W.J.
❑ I. as owner of the property, am exclusively contracting with licensed contractors to
consumer the project (Sec, IGH, Business and Profession Code:) The Conuaclota Ll-
Lcense
causeLaw don not apply in An owner of property who builds or Improv theseon, and,
who contracts for such projects with Aconuwmr(q licensed pursuant to Ore Contncmoea
License Law.
❑ I am exempt under Seo .B At P C for Nb moon
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby idEM under penalty of perjury, on, of Iha following dnclaAllons:
1 have and will maintain ACcnificate of Carse. to W Haute for Workeea Canpcm
"tion, As provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit Is Banco.
❑ 1 have and will mainuan Worker's Compensation Insurance, As required by Section
3700 of the Labor Cede, for the performance of the soak for which this permit is IuuW.
My Worker, Compensation Inwr.nce carrier and Polity number are:
carder. APolicy No.: 2005ob253?
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section deed nolhecomphan t ifm6e permh is for one hundred dollars (SIM)
Or lcsa.)
1 cenify that in the perfmon. of the work for which this permit is issued. I shall not
employ any person in any meaner an u in become wbjmt to [be Worters'Compeuallon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become object to Ne Worker's Compensation provisions of Ne Ichor Coda you mum
forthwith comply with such prevision or Nis permit.hall be deemed revoked.
CONSTRUCTION LENDINGAOENCY
ac10N
1 hereby Ne Vert iss lending "coq for Nc lerformahwe of
,
ed (Sec 3
chthi
the work for which this permit is laved (Sec. ]091. Civ. C.)
LerMrs Name
'
Lenders Address
1 1 cenify Na 1 have read this Application and nam Na %e also. Information Is
corrett i ares to comply with all city and county ordinances and Aute law, relating to
Wilding construction, and Wreby authodm represenmiv of this city to enter open Nc
aha. -mentioned property for inspection purposes.
i (We) agree to save, indemnify and keep humless the City of Cupertino against
j luntides,judgments, cost, and expen"s which may in my way accue again) mid City
In wrtsegnrcc of the gaming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS,
Re -roofs
Type of Roof
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Sitrmure of Applinn n r DM
MATERIALS DISCLOSURE
HAZARD
Will the applicant or futem building occupantsu re or handle hamdous mamdal
As defined by tin Cupertino Municipal Code. Chapter 9.12, and the Hesith and Safety
Code, Section 35533(.)7,
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining ani inspection, I agree to remove
Will the applicant or foam ban sing aceupAm use equipment or dcvimu which
m haallous is wnuroiants u defined by the Bay Arta Air Quality Management
all new materials for inspection.
OiwinT
Ym
I have mad the ha"rdou,mMsials requirement, on&, Chapter 6.95 tithe CAbfor.
nis H"ids&SaBlyCode, Sadat 25505.25333 and 35531. I underm olthMfNe Wilding
dose not cunermly W. A tenant that It b my mal oramithy in notify thA..,.I of six
requirements which must be met me, to hats otwp"cy.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
Owner a smhodmd ahem Dam