04090107Y;
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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
g ONTRACTOR TNFORMATTON
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITN'b4090107
1 503 STEVENS
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
LLD909 ALMA STREET
04/20/2005
NE:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITEC1'yENGINEER:
BUILDING PERMIT INFO
BLDGELECTLUM
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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1 Wmby affirm that 1 am licensed under provisions of Chapter 9 (commencing
with Sued. 700D) of Divhian 3.f de Businw and Preimumns Code. and my license Is
In fell to= andefTeca
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NEW CONDO -1130 SQ. FT.
License ass Lle.•
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ARCHIIECPS DECLARATION
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I undo mu Y Pnt a h a a1'pubHe meards
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Licensed Profcaho mi
OWNER -BUILDER DECLARATION
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1 hmhy affirm that I Am exempt from the Contractor'. License Law for the
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fallowing mason. (Section 7101.5, Business and Profession Code: Any city or county
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which requires a permit m construct, alar. improve, demolish, or repair any stratum
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prior in its I..=. aim rryuires the applicant for such permit to Ole. signed summer,
the Conlrsotors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
dot he is licensed pursuant to Inc provision of
(commencing with Sedan 7000) of Division J of the Busineas and Profession Code) ca
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that h is exempt tiemfmm and the beta for the alleged Assumption. my YmladUA of
AIN Number
Occupancy Type
Section 705 1.5 by arty Applicant for a permit subjects the Applicant in a civil penalty of
not more Nan five hundred dollars ($500). 1
0 I, as owner of the property, or my employees with wages As dmir sole compensation,
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Required Inspections
w111dotiewusk.andthemuctum is not nundedm offered for We(Sao. 704/. Business
and Profealon Cade: Th Connors License Law don not apply In an owner of
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property who builds or improve thereon, and who does suchwarkhimselfor through his
awn employ=. provided that such improvements am m,, Intended aro@red for sale. If.
however, the building or improvement is sold within one year of ampledon. the mass.
builder will have Ila Wrden of proving that he did not build or Improve for purpose of
ale.).
0 I. as mvnes of the property am emWsively contracting with licensed mnuacum in
construct the project (See. 704, Business and Professions Cade:) The Conuseme. U.
cone law does not apply in an owner of Property who Wilda or Improves memon, and
who comment for such pmjeeu with a eonu clor(s) licensed pursuant An the ContncuYa
License law.
0 lamemmptunder Sec ,B&PCforchtsmaon
Owner Dam
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WORKER'S COMPENSATION DECLARATION
I hereby a(fim under perWty of perjury arc of the following dalan0anr.
1 haw And will maintain in.CeNncam of Consent to selGinum for Wall's Compen.
sation, As provided for by Section 5700 of ms Labor Code, for the performance of the
work for which this permit is Issued.
0 1 have and will maintain Workers Compensation Insurance, As required by Schon
3700 of the Labor Cade, for the performance of the work for which this pemll is lamed.
My Workers Compensation Insurance Gamier and Policy number au:
Cartier. jimda-57rc I`PC Policy No.: C�� -mss isr
CERTIFICATE OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
musscetim recd not tecompletcd NOW, permit Is foram, hundred dollars (SIM)
or Ins.)
I ceNfy that In the perfomaocc of she work for which this permit Is issued, I shall not
employ any person in my manm,rso As in become subject in tin Workers'Compenadan
Laws of Cairo rna. Dau
Applicant
NOTICE TO APPLICANT. If. &Act making this Cenifiau of Exemption. you Should
become subjm An the Worker's Compensation provisions of the Labor Code, you mug
Qforthwith
comply with such provision or this Permit shall h deemed nuked.
tiCONSTRUCnON
LENDING AGENCY
1 hereby Million that them ler concoction lending agency for the performance of
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the work for which this permit Is Issued (Sec. 5097, Civ. C.)
QLenders
Name
Lenders Address
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I certify that 1 have mad this appliadon and gats Na the Above informal. is
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morn 1 Agra Io comply with all city and county ordinances and sum laws relating in
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Wilding construction, and hemby anchorite representatives of this city w enter upon We
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above-mentioned Property forinapeedm purposes.
Mott to ave, indemnify and keep hsmlea the City of Cupertino ANW,
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liabllhdes,Judgments. costa and expenses which may In my wayacra galnstmid City
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in consequence of the Starting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATI
Re -roofs
Signature ofABpl ca lConuacm Dau
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant or future building occupant Mom orhandlc Iuallous material
As denned by tie Cupertino Municipal Cade. Chaplet 9.12. and the Halth and Safety
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de. Season 255524)7 Z
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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 the applicant or future Wilding occupant use equipment or devices which
it hazardous air contaminants As donned by the Bay Area Air Quality Management
all new materials for inspection..
ImDIstrict?
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have mad the has doua material, mquimmenu under Chapter 6.95 oftie Califor.
Hal" Safety Cade. Sade ersucurrently25505.25555 and 25534.1 undmotifde Wilding
es not currently haw a mnam Nat h u my responsibility ft notify occupant of the
quirements which mug be met prior to issuance of a CcmOcee of Occup amy.w
Signature of Applicant Date
All roof coverings to be Class "B" or better
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nerar aachnage oars