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CITY OF CUPERTINO_X
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NIb4090110
19503 STEVENS CRK # 219
OWNER'S NAME:
PERMIT' ISSUE DATE
CUPERTINO HOUSING PARTNERS
LLD909 ALMA STREET
04/20/2005
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SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/PNGINEER:
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BUIIDINO PERMrr INFO
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Y�LICENSED
CONTRACTOR'S DECLARATION
Job Descri tion
I hery ainren Net i am Burma under provisions of Chapter 9 (commencing
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with Section 7000) of Division 3 of the Business and profession, Cade. and my lien...• is
"I Ittffo�uasnd efrea
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NEW CONDO -1130. SQ. FT.
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ARCHITECTS DECLARATION
I urtdemund my plane shall a used As public retards
Licensed Profa i...I
OWNER -BUILDER RATION
f ma the Law for dry
I hereby .(firm that I am exempt from the ContractorsLicenseCode:
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reason. 7(1313. Business ad Pre. os Any city
followwhich
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stcounty
t demolish.omash any structure
which e a permh re cavwcL Blue improve.
m permit
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iu; in ermittri
prior to its iuuam,esurcgWra
hclallc.nWthSection70the inions of thnuchpertue.Li nsoLaw(ned atetemem
Sq. Ft. Floor Area
Valuation
that pro
ofDivlomafthcComsinessLucnsenconzOpur9
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ndth Division th alhe eedemandon. An vi Cade)or
pthhecfrom and
injexempt
that he B asempt therefrom atl du bull for tits alleged exempdon. Any violation .f
that
$130808
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APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant 70 a civil penalty of
not more than five huMmd dollen (5500).
❑ 1. As owner of the property, or my employees with wages As thebale muspeosetion,
Required IeCt10DS
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will do the woh,and Neantmm len.timended oronemd fmw.(Sec. 7044, Business
end Professions Code: The Conuamo's Lk. law does al apply 70 an oweof
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property who bulldsm Improves themon,and who doessuch workhimselfor thmugh his
own employees• provided that such Improvements are not InuMed oronered rmsale.If,
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however, the building or Improvement Is sold within one year of complem n, du owner.
Wilder NB he" the burden of proving Wt he did not build or Improve for purpose of
alb.).
❑ 1, as owner of the pnopeny am exclusively conuaciinl with licensed eonuacurs to
construct the project (Sec. 7044, Business and Professions Cade:) The Conuscmfs U.
come Law doss not apply An an owner of propeny who builN or improves Nemo.• and,
who conuacu for such projects with a conuxur(s) Imeosed pursuant 70 the COnoacur'a
License law.
0 1 un exempt under Sec. . B A P C for this, reason
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby afnrm under penally of perjury one of the fallowing inclantiom:
1 haw and will mein Wn a Ceniftau of Comment to self -insure for Worker's Compere
noon, a provided for by Section 3700 of the Labor Code, for the perfonnenm of the
work for which this permit is issued.❑
n, required by Section
1 have and will maintain Worker's COmpenssdon Inwnmu
3700 of the Labor Code. for du performance of the work for which this permit is issued.
My Worker's Compemadon Insurance tamer and Policy number am:
Cartier. 010,715%rC I A.C_ POIIry No.: fACl=A_C4_._3_0
CERTIFICATE OF EXEMPTION FROM WORKERS'
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COMPENSATION INSURANCE
(This section need notacomplewd If tic permit is foronc hundred dmlars (SIN)
or ICsa)
1 mniry Nat in the perfum mance of the work for which this permit in issued. l shell not
employ any person in my mancr an As 70 become abject to the Workcri Comlmnsmon
Laws of California. Dau
Applicant
NOTICE TO APPLICANT: IL after making this Certificate of Exemption. you should
become subject An the Worker's Compensation provioons of Ne Labor Code, you mus,
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forthwith amply with such provisions or this permit shall M deemed hemum.
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CONSfRUCDON LENDING AGENCY
1 hereby affirm that dune ler,.ham thm owhol agcnry for du Mg... of
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QUndoes
the work for which Nle permit is issued (Sec. 3097, Civ. C.)
Name
Lender's Addran
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1 certify that I have mad Nis application and suer that the above informaoun is
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comma I lyra In comply with all City And county ordinances and state laws miming 70
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building construction, and heuby authodm representatives of this city to color upon the
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above-mmOonul property for lapec6on purposes.
(Wc) agree 70 save, indemnify and keep Iunnleu the City of Cupertino against
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liabilities. judgntents, toss And expense which may in my way nerve against said City
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in consequence of the grating of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issuedby:9i4j2zo Date
SOURCE REGULATIONS
Re -roofs
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Signuum of Agrncmd ontractm Dau
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HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the appllcat or future Wilding omupatstom orhandlc summons material
As defined by the Cupenirm Municipal Code. Chapter 9.12, and tits Health And Safety
e.Sccuon 25532(.)7
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roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
All roofs shall be inspected prior to any rooulmncnln
Will the applicant or future building meap.nt. a equipment or devices whichm
it hasuaus air contaminants a defined by the Bay Arca Air Quality Management
all new materials for inspection.
strict?
❑Yes
Inia
1 hammed the hazardous mauriabmquimmenu under Chapur6.95 of the Califon
Health& SafciyCode, Sccd.os25505.25533uld25534.1uderstand thatifthe building
ce not currently hew a tena4 that It u my map.mlbility In notify du occupant of the
which mustbe met prior in issuance of Ceniliala of ocapaey.
Signature of Applicant Date
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All roof coverings to be Class "B" or better
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