04090219W
Ua
CITY OF CUPERTINO �+
PERMIT
c$//4v�vvt�tt'i}NE�ra�o+y.�- �g 1�C �2+€:�^y'���zJ*»"-ni�,ai
1o11M�ON
BUILDING DIVISION
41'• a/1i,1VOl1t.
W
BUILDING ADDRESS;
PERMIT NO.
PALISADE BUILDERS INC
04090219
0 E:
PERMIT ISSUE DATE
E;
SANITARY N L NO.
ARCHTITCDP.NGINEER:
BUILDING PERMIT INFO
BLDO ELECT PLUMB MECH
0 t�
LICENSED CONTRACTOR'S DECLARATION
o
Job Description
1 berchy arfirm that l am limned under provisions of Chapter 9 (commencing
with Section 7000, of Division Softhe Business molPPrnfnshnta Code, and my license is
In full force and effecl.
g 8 D N
CIA,- tj
Licomeactor
NEW CONDO - 1320 SQ'. FT.
Cle.111
sts"IFY s
ARCHITECTS DECLARATION
I understood my plain shall be sed a hlle.meorda��
Licensed Professional
OWN ,R•BUILDER DECLARATION
1 hereby affnm that I am exempt from the Contractors License Law for IM
following reason. (Section 703 IS, Businessand Professions Code: Any city or county
which requires a rum it to construct, alter, Improve, demnimh, or repair any atmetun
inner In its issuance, also requires the applicant forauch permltto file s signed Statement
that he is licensed pursuant to the pmvidmu or the Commons License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Businco and Proresslom Code) in
that he is exempt Benefited and tint basis for the alleged exemption. Any violation of
APN Number
Occupancy pe
Section 7031.5 by any spplicsnl for a permit mbjeeto the applicant to a civil penalty of
not mart thug the hundred down ($500),
❑ I, asownerofthe limpeny, ormyemployces with wagesu Nelrsole compewnon,
31620084. OORe uired Inspections '
will do the wort, and the muctum is Act Mounted O ofrewd for sale (Sec. 7011, Business
and Poefmsloes Cade: The Contracm's Limme law does not apply m an owner of
q P
property who builds m improve,themon, and who doessuch wink himself or through his
own employees. Provided that such Improvements arc not Intended oroQered image. If,
however. Ne building or Improvement is mid within on year of cempledon, Ne owner.
builder will haw the burden of proving this he did int build or Improve for purpose of
axle.).
❑ 1, as Ower of the property, am exclusively comrst7ing with licensed comescu n to
mmu ict the project (Sec. 700, Business and profession Code:) The Comexa m's U.
cone Law docs not apply to an ovmer of property who builds or improws thenen. and.
who contracts for such projega with a eon ingtor(s) thima d pursuant to the Cormseto's
License Law.
O lamexemmunder Sea ,BAPCfnrthismamn
Owner Due
WORKER'S COMPENSATION DECLARATION
1 hereby sfBrm under penalty of perjury Oto of the following deehntiom:
have and will emmism aCenificate of Consent an selfdnmm fO WorkeesCompan-
satme. As provided for by Section 3700 of the labor Code, for Alto pert ennarcs of the
work for which this permit is issued.
❑ 1 haw and will maintain Worker's Compensation Immrinm, As inquired by Section
3700 of the Labm Code, for the performance of the work for which this permit Is issued.
My Worker's Compensation Insurance envier and Policy numkr sm:
Cartier: No.:CQLa 63W
�FA%LMON
'
_T�Policy
FROM WORKERS'
COMPENSATION INSURANCE
(This section need not becompleted Ethic permit Is foronc hundred dollars (SIM)
Or less.)
I cenify that In the p i t,,.. see of the work for which this permit Is issued. l still not
employ any person In any mannenn As to become subject to be Workri Compensation
Laws of California. Dale
Applicant
NOTICE TO APPLICANT. If, after making this Cenificate of Exemption, you should
become subject m the Worker's Conmensathm provisions of the Labor Codc, you mug
forthwith comply with such provisions or this permit thall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affine that then Is a conswctim lending agency for the performance of
Old work for which this permit It Issued (Sec. 3097. Civ. C.)
Undoes Name
Lender's Addec s
1 cenify that I have read this application and sum thg the above Information is
collect. I aims in comply with all city and county ordinances and eau laws relating m
hulltlin{ congromion, end hereby anthorie representatives of Nis city to enter upon the
annve mem.... — property for inspection purposes
(We) agree to save, indemnify and kap buddess the City of Cupcnino agaimt
liabilities, Judgments. costs and expenses which may in any way accrue against said City
in
APPL CANT UNDERSTANDSf AIND WILL COMPLY WITH ALL NON-POINr
Issued by: Date
SOURCE REGULATIO
e -roofs
Type of Roof
SI{nature ofA IlcaoVGe or Dau
ARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant tore or handle baioxeous material
At dented by the Cupertino Municipal Code. Chapter 9,12, and the Health and Safely
Code, Section 25532(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yca
If a roof is installed without first obtaining an inspection, I agree to remove
Will the IPPlicsnt or town Wlldin{ meupaor uequipment or dcvims which
se
hanNuua air contaminants As defined by the Bay Area Air Quality Mwgeroml
all new materials for inspection.
grit'?
❑Yin No
1 haw mad the he aNne' maurlemeyuimmenu under ChaPur A.95 of Me Califnr.
ole Health A SaNyCode, Sections 25A)5.25533 and 25534.1 understood thatirthe Wilding
does not currently how a tenant, that It u my responsibility in notify the occupant of the
requlmmcnu which a be rtum met prior manof a Certificate of occupancy.
Signature of Applicant Date
2
All roof coverings to be Class "B" or better
Owner o umorized Dam