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CITY OF CUPERTINO
° G`ONTRACI.OP-13
BUILDING DIVISION PERMIT
BUILDING ADDRESS:
PALISADE BUILDERS INC
....NO04090114
19503 STEVENS rRK it 112
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909
E;
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
p
ed under provisions of Chapter 9 (rocing
Btmmen
1 hereby affirm mal I ama
-
with Section 7410) of Division 3.f the Bus. and profudat Code. and my license lea
full aneert
ggpy6
NEW CONDO -1506 SQ. FT.
License Clea
new Contractor dL?SNac o,ye+
ARCHITECTS DECLARATION
I undersand my platalWl yt :: rde
!`T ujc
Licensed Professional
OWNER•BUIIDER DECLARATION
1 hereby afftrm that I am exempt From We Conuacufs License Law for the
following masen. (Section 713 1.5, Business and Profession Code: Any city or county
which requires a Permit to ennmucL Slur, improve. demolish, or repair any structure
prior m its issuance. also mquirea the applicant forsuch permit to file a signed statement
Sq. Ft. Floor Area
Valuation
that W is licensed puauant to to prevision of the Contractor's Llecnse law(Chapuf9
(commencing with Section 7000) of Division 3 of thc Busincaand Professions Code) or
17 4 3 3 4
that he is exempt memfrom and the buss for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mare than five hundred doll. ($500).
❑ I, u owner of the property, or my employer with wages as, their auto compensation,
3162 U U Ej 4 U URequired Inspections
will do thewmk and the suunare is not Intended or offered retrain (Sec. 7044, Business
and Profession Code: The Contmemes Lkene Law don not apply to an owner of
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property who builds ortmistmes thereon.and whodoessuchwork himself orthrough his
own employcca, provided that such Improvements art not intended stuttered Torah IL
however, me building or Improvement Is veld within one your of completion, the owmor.
bulkier will have me burden Of proving that he did on, Wild or improve for purpose of
ale.).
❑ 1. as owner of me Property. am exclusively contracting with licensed contractors W
construct the project (Sec. 7044, Business and Profusion Code:) The Contractors Lb
cease law docs not apply to an ower or property who Wilds or improves demon, and,
who contracts for such projects with a conuator(s) licensed pursuant to the Conuacura
License Law.
❑ I am exempt under See . B& P C for this rtawn
Ower Dae
WORKER'S COMPENSATION DECLARATION
I hereby arm under penalty of perjury one of the following decimation:
pt
lam and will maintain aCmim a ofConsem to selGlnwrt for Workers Campem
ation, use provided for by Section 3700 of tie labor Code. for the performance of an
mark for which this permit is iaud.
❑ 1 have and will maintain Workers Compeassum Insurance, u mquimd by Secdw
37W of the Labor Code. for me performaec of dee wort for which this permit u issoed.
'
My Workers Compensation Inannce artier and Policy number are:
Cartier NI44.X577L rwL Policy No.: (.2 0.I%3or
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATION INSURANCE
(This wean need notwcompleed If me permit It faomohundrtddellan(SIQD
plea)
1 earth that in the performance of tho work for which this permit is Issued. I shall not
employ any person in any maMr an a in become abject loge Worlmrf Compensation
Laws of California. Dau
Application.
NOTICE TO APPLICANT: If. &Act making this Certificate of Exemption, you mould
become subject to the Worker's Compensation provision of the Lader Code, you most
forthwith comply with such prevision or this permit shall W dcemcd revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that thea It. construction lending agency, for be performance of
am work for which this permit is issued (See. 3097, Civ, C.)
Lender's Name
Lender's Address,
1 certify that I have read this application and sum mat the above information is
campcL I agmen to comply with all city and county ordinances and sass laws milting to
building convection, and hereby euthodne representatives of this city to enter upon the
a owe-mentutd properly for Inspection purposes.
(We) agree to save. indemnify and keep hamina the City of Cupertino against
Ilablllim, judgments, costs and expense, which may in any way acne against said City
9
in
APPLICANT UNDERSTANDSof IANhisD WILL COMPLY WITH ALL NON -POINT
Issued by: Date
�
SOURCE REGULATS.
Re -roofs
Type Roof
r ^i Li5 '(
Signature ofAPpll n=W Data
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or futum Wilding Occupant store uhadle h xuddous material
as; defined by the Cupertino Municipal Code, Chapter 9.12, and tW Health and Safety
C.4.'Seeders 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
❑ Yu o 1
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant at future Wilding aaupant use equipment Or devices, which
it haardous air commomats u de0mod by the Bay Area Air Quality Maagaeal
all new materials for inspection.
Dist kit
Yu
I have read the haaNmtsmatedalarequmurents underChaper195orde Califm.
nu Health & safetyCode. Seetitw25505,25533 and25534.1 unhnuM ft Ease Wilding
does mel currently hew Sunset. that It u my responsibility to modify ge occupant of the
mquimmcna which most be mel prior w kaaama of a Ocrfndc of Occupancy.
Signature of Applicant Date
�" ����'� y-�f. s�
All roof coverings to be Class "B" or better
Owner ser Guth ad agent Date