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CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMffN"04090104
19503 STEVENS CREEK jil0c;
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA ST
2005
E;
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER;
BUILDING PERMIT INFO
BLDGO PLUMB MECHO
O
LICENSED CONTRACTOR'S DECLARATION
lb Description
o
I hereby anus that I am licensed under proviaiou of Chapter 9 (commencing
p
with Sm&n 70(10) of Doubts 3e1' the Rudneos and Professans Cade. end my license u
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Liman Tome andtRmL
3
NEW CONDO -1558 SQ. FT.
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DELL
ARCHITECTS DECLARATI N
I undersundmy plea slWlW uhllc meet&
Licensed Plucssmnsl
OWN BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors License Lew for the
following mann. (Section 703 1.5, Business and Professions Cade: My city or county
which requires a permit to cummael, slur, Improve, demolish, or repair any structure
prior to its Issuance, also requires the applicant for such permit to Ble.signed statement
that he is licensed pursuant to the provisions of the ContractorsLcense Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Codc) or
$180354
that he u exempt therefrom and tae but, for the alleged eumplion. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit anbime, the applicant o a civil penalty of
not more than five hundred dollen ($500).
❑ I. as owner of the property, or my employees with wages as their sole comlmentr n,
3 t620084.00
Required Inspections
will do the work, and uaaoucwo: I. not intended or offered ferule (Sm. 7044, Business
and Profewdons Code: The Contractors Licemm Lew don not apply to an owner of
property who WII&orimproves moment, and who Oatsueh work himselforti rough his
own employee. provided that such improvements ane not Intended oso@ted for We. If,
however. the building or Improvement Is to within one year ofcomple&n, the owmr
builder will ban the burden of proving WI he did not Wild or improve for purpose of
tau.).
❑ 1, as owner of the Property am eaelnsiwly contracting with licensed contractors he
construct the project (Sec. 7014, Business and Pmusslou Code:) The Comraclors U.
mese Law don not apply to an owner of property who Wilda or improves Nemon. and,
who concocts for such projects with a contrumr(s) licensed persons to tae Contractors
License law.
❑ Iamuemptunder See .BkPCfosuisreawn
Ower Dau
WORKER'S COMPENSATION DECLARATION
1 hereby Jfires under porosity of perjury ane of the following declantioroe
I ham ane will maintain •CeNficate of consent to"If.h.um for Workers CMbPm.
urian, u Provided for M1Y Section 3]00 of the labor Ca&, for she performance of the
work for which this permit is issued.
I have tad will maintain Workers Compensation loado m, u required by Section
3700 of the Labor Cade. for the performance of tae work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number me:
Cartier: 04/t--57, 7 b!-. PolicyNo.:C-�0�'dY7.iJ33Liy
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section wed not W completed if the Forth is farow hundred dollars ($IN)
.less.)
I cenify that In the performance of the work for which this Permit is issued. 10.11 not
employ any person in any manner an as W bmomc subject to the Workers'Compcnwlan
Laws of California. Dam
Applicant
NOTICE To APPLICANT: It, after making this Ontinuu of Exemption. you should
become subject to the Worker's Compensation provisions of the labor Code. you must
Forthwith comply with such provisions or this Permit shall W rimmed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby alarm that there is a construction lending agency for the Performance of
the work for which this permit is issued (Sm. 3097, Civ, C.)
Lenders Name
Lenders Address
I certify that I haw mad this application nod cote than the show infmmaden is
corms. I agree to comply with all city tad county ordinances and sum laws mudins he
Wilding construction, and W mby anthorin representatives of thiscity to enter upon tha
anew-mcndoncd property for impecdon pmpmea
(We) agree to an. indemnify and Imp hatmlra the City of Cupertino against
liabilities, judgments. cum and cap. which may in my way scathe against mid City
in consequence, of the
APPLICANT UNDERSTANDS AIND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURC ULATIONS./,�
Re -roofs
Type of Roof
/
�e�` 47 45—
Signature ofApplkan ARDO Date
HAZARDOUS MATERIALS DISCLOSURE
Will too applicant or forum Wilding h
atom Orhandlethe
Health and
u de0ned by IM Cupertino Municipal Cade. Chapter 9.1x, and du Health tad Satiny
e. Clupl
coda, sae❑uan 25532u)?
Yes les
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
FWill the applicant or future building Occupant use equipment or devices which
it haurdoua air emomminam e u &nncd by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yu
I have mad the hvarthma mauriahrequiremenm under Chapier6.95 of the Califor.
ni4HcRl" Sd%yCadcP Smtions 25%5,25533 and x5334.1 undentsM thatifthe Wilding
does not currently hew a tenant, that it is my responsibility to notify the Occupant of the
requirements which must be met prior In Issuance aft Cenincam of Occupancy.
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Signature Of Applicant Date
, o
All roof coverings to be Class "B" or better
Owner or amh rn om Date