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BUILDING DIVISION PERNIIT,CON'I'12'AC^TURINFr1TIQ
Bu1LDING ADDRESS:
PALISADE BUILDERS INC
PERMITN�4090112
19503 STEVENS CRK # 158
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA ST
2005
NE:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm that 1 am licensed under provisions of Chapter 9 (commencing
P
with Section 7000) of DlvWon 3 of ins Buanea and Profenitm Code. W my license is
Infulfaaeandeffet. A39 *""4
NEW CONDO -1506 SQ FT.
Lkenan Clan Lk. 0
Dam Contractor Yu9 %Jgdn 1410
5
ARCHr=S DECLARATION
I understa of my plans�syyaaBB be use ayp�ihlto recerde
Licensed Pmfeuianal T
OatNEm BUILDER DECLARATION
I hereby .(Sero that 1 s License taw for the
exempt from the Cssion
um My city m county
following rtasan. (Saito 71131.3. Basun. and Code:
1.
ve. de pair ttemure
which i ms a permit to ennatruc4 aimr, imPmve, demolish. ri
its e ed
prior w its issuance, also coquina the applicant for such permit cuto file s eLaw (Chapter
Neth iNieemcJ pursuant to On provisions of the Comrsctohli�cense law (CTepwr9
Sq. Ft. Floor Area
Valuation
(commencing with Section 7000) of Division 3 of tie Business and ProfesinnsCom)at
$174334
dist he is exempt therefrom and the basis for me alleged eumption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by A" applicant for a permit subjects the appiku'to a civil penalty of
nm mom dun five bu almd dollars (5300).
❑ I. u owner of tie property, a my employee wW wager u theirmle companvdon,
Required Inspections
willda thewark. and dmwucwm is notintmW aoffertd forsale(Sm. 70th. Buainess
and Prorestlons Cade: The Conmctoh License Law doe net apply m an owner of
9 P
property who build or impraKa deseon. and who aces such work by Mel f ar tiuough his
awn employee, provided that such improvelnenu art not intended croRered fosale. If,
however, the building or Improvement Is Bold within oro Sear of compledon. the owner.
Wilder will have the burden of proving that he did at build or improve for purpose of
sale.).
❑ 1, u owner of the property, am uclusively contracting with licensed contractor, to
construct de pmjat (Sec. 7044, Business and Professions Coded The Comtracmrs U.
cc= Law dors not apply m an owner of propeny woo Wilds or improv thereon. and,
who conma5e far Such projects with a eonuaator(0 licensed pursues to the Contramars
License law.
❑ I am exempt under See .B k P C ray this won
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penury of perjury ane of the fallowing dcclarnions:
1 have and will maintain a Certificate, of Consent to xlbinsum fa WorkerSCompen.
sada., u provided fm by Secdon 3700 of dw labor Code, far the peRormame of the
work for which this permit is Issued.
❑ 1 have and will maintain Warkefs Compensation Insurance, as required by Section
37W of ter labor Code, for the performance of the work for which this permit Is Issued.
My Worker's Compematlon lax mae Cartier and Policy number are:
c'�
Cartier. /N41T'6Z,< T' r Polity No.:f.90sYD.TaLS�.i QS
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thh sermonrc nobecompleted Ifte permit Is form huMred dollars ($101))
or leu)
1 certify that in Ne performance of the wort fa which this permit ts issued, I mail not
employ anyperean In any mayor rat a m became subject to the Workere CompcmUon
Laws of California. Dow
Applicant
NOTICE TO APPLICANT` IL after making this Cedincaw of Exemption. you mould
become subject to the Workers Compensation provisions of the LaWr CMC, you mum
forthwith Comply with such prov,mau or this Permit mall be deemed mvaked.
CONSTRUCTION AGENCY
uP.NDING
1Mrwh Term thatthere ten ding ageacy for the MRurmence of
theLt work (or whim this peymil V iuwd (Sec. 7097, Civ. C.)
issued (Sao.
Landers Namc
Lenders Address
I certify that I have read this application and sum the the above information Is
coned 1 agree to comply with ail city and county ordinances and SUM laws MIMing to
building Construction, and hereby authorize representatives of this city tocnla uPnn the
above-mentioned property for impeedon pmpnes s.
(We) agree to save, indemnify and kap humkas the City of Cupertino against
liabilities. judgmems. costs and expenses which may in any way mane against Said City
I. consequence of the treating of this panni'.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATION�S. �—�/
-
AAZs�—"
Re -roofs
Type of Roof .
6`44
Signature of Applicanyy2E atyactor Data
AAZARDODS MATERIALS DISCLOSURE
Will the applicant or future Wilding occupant mom ahandle haardous material
as defined by tie Cupertino Municipal Cade, Chapter 9.11, and the Health and Safety
Code. Section 25532(a)7��. ���111
All roofs shall be inspected prior to any roofing material being installed.
Ely. $No
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will line applicant or future building occupant use equipment o devices which
It hazardous air cmumlmnts as defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yin
1haveread the huaNaumm dalsrequimmenuum rChapwr6.95oftheCalifor-
maHealth It Safety Code. Sociom 25505.25533 and 25534. I undenund lnatifthe Wilding
does not Carmody hew a mnan4 that It b my respomibility w notify at Occupant of the
reyubcmcnts whicnmum be me p'iarmiuuancear.crnirreawarawPenry.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Owner Or mftriwd a nt Dam