04090117CITY OF CUPERTINO
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BUILDING DIVISION PERMIT
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0u1LONG ADDRESS:
PALISADE BUILDERS INC
PERMIT"004090117
19503 STEVENS
OWNER'S NAME:
MIT
PERIESUB DATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
04/20/200S
NE:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECUENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
lb Description
9 (commencing
I hereby affirm that 1 am liaised under provisions of Chaptero
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with Sued. 7=).f Division 3ef the Busineseand Preload.. COCA, and my he.. Is
in full fM.Ge.
License Lic.0 338
NEW CONDO -1487 S Q . FT .
Date Contractor
ARCHITECTS DECLARATION
1 unM nJ my pl�lyp esu . Mic rtcor0
Ig
Lkennd Profc
OWNER -BUILDER DECLARATION
I bereby.(Sere l sump, from the Coninttofs
Anyc Lew for The
Code: Any tiny or county
following rtuaa (Section Icon I.S, alnw and :
on 1.
vefassiuns
construct, or mash any
which require • permit WOi=heHue improve, demolish
Permit t
statement Prior Wits
cenedpAlso requima Noapplicant for suchpermitWfiles,Law suumem
licensed in the Provisions of the law(Chodur9
Sq. Ft. Floor Area
Valuation
(dom comma and Pr
the Business and Code) or
(commencing with SecJon 7000) of Division 3 the
Secalot
$172135
on. Any
that be is uempt Jumfrem and the bub for the tllo{cd exemption. Any violNon of
f the eg
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit aubjeeta the applicant W a civil petty of
not more dun five hundred dollars (5300).
❑ 1,mewnsrofthepmpeny,mmycmploy withwagesuthe4mlecompennom.
Required Inspections
will do the wark, and the structure is not intended orortertd foreHe(Sec. 7044, Business
and Professi.0 Code: The Contractor, Liar Law dome not apply to an Owner of
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property who Wilds orimproves dterean, and who doessuch work hinuelformuough his
own employees. provided that such impruvemmts art notiniended oraQercd fee Bale. If.
however, the building or Improvement is mid within one year of completion, ire owner.
builder will have the burden of proving But he did not build or Improv for purpose of
ilio.).
1, as Owner of JK property- am exclusively contriving with licensed commons in
,
construct the project (Sec. 7044, Business and Pretensions Code:) The Contractors Li-
ar law does not apply W an owner of property who builds or improve thereon. and,
who Contracts for such projeeu with a eonusewr(s) Iicent d pursues W me Conueeme.
Llc.. law.
❑ 1 em exempt under Sec. . B R P C for this mason
Owrur Dau
WORKERS COMPENSATION DECLARATION
1 hereby aRirm under penalty of perjury one of the following devlxmIIOA :
I ham std will maintain a Cmdfiate of Comm, u nifAnsure for WorkNs Compen.
satlon. u provided for by Section 3700 of the labor Code, for mo perfmmamv of the
work for which this permit is issued.
❑ I have and will maintain Worked Compensation Irnna. as required by Section
3700 of the labor Code, fm mo performance of the work fee which this permit is named.
My Workers Compensation Immrina carrier and Policy number are:
QMer: �443*;-.'3%r C Z -y C Policy
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section need not becompleud If the permit Isforonc hundreddollars ($1130)
mks[)
I unify that in the performance of du work for which this Permit Is Ives. I shall nm
employ any person in any mannerm of W become subject o the Workers' ComPensadon
Laws of CHif.Amm. Dau
Applicom
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject W the We leer's Compensation provisions of mo Labor Code, you must
forthwith comply with such provisions or this permit shall be decmtd mwked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that them Is a construction lending sjeecy for Ju Performance of
the work ray which this permit is issued (Sec. 3097, Civ. C.)
Lerders Name
Landes Add.
I certify mat I haw read this application and smut the, the above InfmmNun b
corms I agree W comply with all city and county oNlnarcvs and state Iowa relating to
Wilding couOuction, and hereby authorho mpresenudws of this city W CAW upon mo
aheve-mentiuned PMPeny for I.pecden PurpOJCL
(We) agree W caw, indemnify and kap hmmms, the City of Cupertino against
liabilities, judgments, costs and expenses which may in my way a<rnu against aid City
in Consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
a
Signuurt of Applican =me Vete
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building eccupantamre or herdic hUNdOu) material
u dented by rise Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Code. Section 25532(0?
All roofs shall be inspected to any roofing material being installed.
13 you,
prior
If a roof is installed without first obtaining an inspection, I agree to remove
Will the eppllcanr or future building occupant use equipment or devices which
It haserdous air contaminates as Jefintd by the Bay Ama Air Quality Management
all new materials for inspection.
Diuricn?
❑ Yu
I have reed me huaNnusnationals mqulremcw under Chapter 695 of the Collins.
Cut HalmBSolely Code, Semims 23305.25533 atd 25531.1 understood that ifile building
dao Amt currently have • unan4 that It b my respe.ildiny W notify the occupant of the
mquimmenu which mustbe Am prior 'iuemce or a Ceruficate of occupancy.
Signature of Applicant Date
�`"" �— {� �� `�
All roof coverings to be Class "B" or better
Dow Owner sir amh
and agent _
Is