04090106CITY OF CUPERTINOv3'.84^
" °
TNF.(SRMA"CTON
BUILDING DIVISION PERMIT�'CONSTRACR
BuEDING ADDRESS:
PALISADE BUILDERS INC
PERMITN�4090106
19503 STEVENS CRK 339
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
04/20/2005
g;
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MECH
0 0 0 0
LICENSED CONTRACIVR'S DECLARATION
Job Description
1 lumby aRirm that I am licensed under provision of Chapter 9 (Commencing
with Section 7") of Division Sof the Busiosss and Professions Code, and my license is
in rmil force and effect.
NEW CONDO -1130 SQ. FT.
Lkensu asa
.•
Dau Contractor
.)
ARCHITECTS DECLARATION
I unm n my hns ehali bo w purer rteorm
Licensed Professional
OW .BUILDER DECLARATION
1 hereby afr m that I hon exempt them the Contractor's License Law for the
following mason. (Section 7031.5, Business and Professions Code: My city or county
which requires a permit On consumar after, impmw, demolhh, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
that W is licensed Foment to the Provisions of the Contractor's mnse Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of the Business and Professions Code) or
$130808 a
that he is exempt therefrom and the baso for the dlcgcd exemption. Any vlolNon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects old applicant to a civil penalty of
not ream than R. hundred dollars (5500).
0I,uownmofdiepmpeny,wmyemployeeswimwage3uthe wicampens{don,
Required Inspections
willdatheworktandmeatrm:turetsnm imendedoraffemdmruk(Sec. 70M. Bwdma
and Pmfessimu Code: 7%C Chummier. License low does trot apply to an Owner Of
q P
Property who builds o i mprowo durmn, end who does ouch wok himself or throu{b his
Won employee. provided that such improvements art oat intended MOROCCO for sale If.
however, to Wilding or improvement is old within mu year of Completion, the owner.
Wilder NR have the Wrdcn of proving that he did an, Wild or Improve for purpose of
esu.).
0 1, a Owner of the property am exclusively contracting with licensed Contractors to
construct the project (Sec. 701.1, Business and Professions Cade) The Comncurs Lb
cense law does not apply 0 an owner of property who Wilds or improves dumm, and,
who contracts for such pmjem with a conmetar(U licensed pursuant to the Contractors
License law.
O l un exempt under Sec. , B h P C for this mason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 thereby arm under penalty of perjury ane of the following declandau:
I haw and will maintain a Certificate of Consent to selbinsum for Workers Comper-
saion. as provided for by Section TIM of the Labor Cade. for the performance of Use
wok for which this permit is owned.
0 1 haw and will maintain Workers Compensation Insurance, u inquired by Section
3700 of IW Labor Cade. for the performance of the work for which this permit u Wiled.
My Wof e, Compensation Insunue Cartier and Policy number am:
Carrier. AJ1ge Tie M& Policy No.: CSOMo�mD.3
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
CrInds section need not bemmPlend if the permit Is fmonc hundred dollars (SIM)
or len.)
1 « nify that In me performance of the work for which this Permit Is lamed. I shell not
employ any person in any manner out as in become subject to the Worked Compensation
Law, of California, Dau
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
Wrome subject to the Workers Compensation provisions of the lahm Code, you moat
Forthwith comply with such provisions or this permit shall W deemed unused.
CONSTRUCTION LENDING AGENCY
1 hereby affirm out then Is a comman dan lending agency for the performance of
the work for which this permit is issued (Sec. 3097. Civ. C.)
Lenders Name
tender. Address
1 certify that I bow read this application and said that the some information Is
'
comma l agree to comply with all city and county ordinances and sure lam relams in
building construction, and hereby sumoris representsOwa of this City to color uPnn the
above-mentioned property for inspection purposes.
(We-) agree to saw, indemnify and keep harmless the City of Cupertino against
.
liabilities, judgments, cuss and expenses which may in any way wane .gams, mid City
In consequence of the {sanung of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATI S.
Re -roofs
Signatum OfA IlcantlConmacmr Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future Wilding OCCupantwore an handle hoodoos mauriH
u denocd by the Cupertino Municipal Code. Clupar 9.11. and the Health and Safety
cam. Section 23531(.)7
❑Yes %No
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 me applicant of future building Occupant use equipment or device, which
mh hazardous air contsmlnsna he defined by the Bay Ams Air Quality Management
all new materials for inspection.
DlnricO
4.
OYcs
I hew mad the hoar hes. materials requirements under Chapter A95 of Use Califor.
OFHealth @ Safety Code, Se dos 13505,25333 and 75534.1 undo Bund that tribe Wilding
does not currently how a uvam, that it ts my responsibility in notify the Occupant Or the
requiremenn which must W met prior On issuance of a Certificate of Decupancy.
Signature of Applicant Date
.a
All roof coverings to be Class "B" or better
Owner or uthorim em Dau