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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
9
= CONTRAC�TOR INFaO'RMATTgN
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SUILDINGADDRESS:
501 STEVENS CRX if R
PALISADE BUILDERS INC
PERMRNb4090102
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTINERS
909 ALMA STRRRT
n4/20/2005
SANITARY NO. CONTROL NO.
650)470-4700
ARCHITEC IENGINERR:
BUILDING PERMIT INFO
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BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
I Mreby affirm Net 1 am licensed under pmvisiou of Chapter 9 (Commencing
with Section 70M) orDivlsion 3 of da Business and Prafesvoas Code, and my license is
Kroll rartx enaeacet. g 300 6
_NEW RETAIL BLDG. B (3868 SQ. FT. )
License Cl
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Dao: /� vSADC
ARCNITECT9 DECLARATION
TS DECf
I uMcrwnd my plw 1 ublie rtca
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OW -BUIMER DECLARATION
1 hereby affirm Nal I Am exempt from the Conua tors Lt... law far Ne
,
following reason. (Section 703 1.5, Business and Professions Cade: My city or County
which mqulms A permit to Armor et, Alar. improve, demolish, or repair any swetum
prior on its issuance, also requires the applicant for such Permit to file a signed comment
that M is licensed pursuant to the provisions of the Communes Liumm Law (charter 9
Sq. Ft. Floor Area
Valuation
(commencing with Sudan 7000) of Division 3 of the Business and Prof asinnsCodo) or
$362702
dot Mb excerpt damsel oro and da bash for tie alleged excmpdon. My violation of
APN Number Occupancy Type
Section 7031.5 by Any aPPilemt for a permit subjects the applicant to a civil penalty of
am mom Mm Bve hundred dolWs (5500).
❑I,oownueflMpropenymmyemployeuwithweguuNeirmle Compenudon,
willde Newark, and theswcluretsmlimandedoroQered ferule(Su.7744.Bwinrsa
ma Prafcsdons Godo: The Gastronome, Lkeue taw don Trot apply b m owner of
Nemsn, senawM
em whos.
?
l -UU Required Inspections
1 - q p
areaemhwort croft ldWaugh
man providedatsu improvements roam
cmndedmaRered(he caner-
however, thecs,provided prove Ant is Wier of Completion. Neewur-
however,the or Improvement lsaaldw
dii an,
builder will have Ne burden of proving Nu be ilia ext mild or improv for puryae of
use.).
0 1. as owner of who property. am eaelu mly contracting with licensed cnnuunms to
construct the pmKa (See. 7016, Business and Profusions Cade:) The Cor lncmr's LI-
ccnse law does not apply to an owner or property, who builds or implmex Marmon, and
who contracts for such pmjecm with a contractor(s) licensed pursuant a the Convectors
License Law.
0 1 Am exempt under Sec. . B A, P C for Na daasov
Owner Dow
WORKER'S COMPENSATION DECLARATION
1 hereby Label under penalty of perjury one of was following decimations:
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i have and will maintain ACalOua of Consent m self-insum fm Worker's Control.
older, As provided far by Sudan 3700 of the labor Code. for the put... of W
work for which this permit Is Issued.
0 1 have and will maintain Worker's Compensation Insurance. As required by Section
37M of the lobar Cade, for the perfarmanee of Ne work for which this Permit Is Issued.
My Workce, Compensation Insurance carrier and Policy number are:
C.M.r,rd N 7e,5 7,;z 7/t,G (/aa'i Policy No.: 0.26000—i`6
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATION INSURANCE
(This section need rat N completed little Permit Is faros, hundred dollars (SIM)
Or los.)
I CeWiry that in the performance of tits work for which this permit is island, I mall not
employ any person in any mannerso es on became object o the Worker' Compensation
Laws of California. Dao
„
Applicant.
NOTICE TO APPLICANT. IL alar making this Certificate of Exemption, you should
became subject as the Worker's Compensm o provisions of Ne labor Cade. you most
foMwith comply with such provisions or thin permit shall W doomed rooked.
CONSm ON LENDING AGENCY
is a c lending Agency for Mc performance of
I herby eRrm thm a is •
n rad (m . 3
work (or which Nle permit ts wua (Sts. 7097, Civ. CJ
Le
Leaders Name
,
Lenders Aedm••
1 Cully that I have read this application and ansa Nat M, above InfomdNun is
'
COMM I agrra to Comply with all city and county ordinances Ana sum law relmng w
Wilding construction, and hereby authorise reposemuiw of Nis city to enter upnn tits
give -mentioned property fm inspection purpoat
(We) agree is row:, Indemnify and keep hnmiw M, City of Cupertino Against
liabilities, Judgments, cera and expenses which may in my way accrue against mid City
In consequence of Me granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS
Re -roofs
y-ai os
Signmurt of Applies on nmor Dow
MATERIALS DISCLOSURE
A2Aform
Type of Roof
Will the applicant or form building occupant Rode or auntie
b
Health and
u doRu4 by Ne Cupertino Municipal Cade, Chapter 9.13. and the NeJN and Safety
Cade. Sudan 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Y,s e
a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant Or, foluraauding Occupant use equipment or devices which
Coll bandana air contaminanta As dcOnca by Ne Bay Arta Air Quality Management
all new materials for inspection.
DisuicO -155�I�,
[]Yes 3.1
1 have mad the hralous materials requirements under Chapter 6.95 of the Califor.
nil HcalM k Safety Cade, Sections 25505.35533 and 2553/. l understand that ifW building
doss not currently haw a anal. that it a my Iceponobilily w notify Me ottuPmt of the
mquiremmiswhicha"Ito arwwm
ac,.r.CaniOcateor@npmcy.
Signature of Applicant Date
— onto
All roof coverings to be Class "B" or better
owner ar.athari d rat
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