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CITY OF CUPERTINO
BUILDING DIVISION PERMIT
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6u1LDINGADDRESS:
PALISADE BUILDERS INC
PERMITN0.04090119
1 503 STEVENS rRK ft 12n
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMBO MECHO
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LICENSED C0NIRACI0RI DECLARATION
Job Description
1 hereby affirm that 1 are licensed under provisions of Chapter 9 (commencing
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With Section 7010) of Division 3 of tho Business and professions Codd, and my license is
In full tome and Whet,p
NEW CONDO -1487 SQ. FT.
License Class Lk. Y
9PA14,5401
Dam Contractor fol,
A CHITF,CI•SDECLARATION
'
b./e wlpl u public memJs
I uwaml
Licensed Professional' ✓ _
OW NER-BUILDER DECLARATION
1 hereby a1Rrm that I am exempt from the Contractor. License Law for me
following reason. (Section 703 1.5, Business and Profession Code: Any city or county
which requires a permit to construct, alter. improve. demolish, or repair any structure
prior to its issuance. also requites the applicant for such permit to file signed Mtoment
Ft. Floor Area
Valuation
that he is licensed pursuant to the previsions of the Common's License Law(Chapmr 9
Sq.
(commencing with Section 7(100) of Division 3 of the Business and Prolamines Code) Lir
17 2 13 5
that M h exempt therefrom and the bash for the Ilcgcd assumption. Any violation of
APN Number
Occupancy Type
Section 70315 by any applicant far a permit subjects the Applmuts M a civil penalty of
not more than five hundred dollars ($300).
❑ l,udwmraf Neproputy,mmyemPloycuwiN Vsuthelrwleeampcmu on,
1152 0 MM Required Inspections
winds thewerk, wdweawnareisommmndeAmnReaed forsak(Sec.7044,11udthem3
de: ouannrs License Law does not apply to m owner of
and Professions CoThe Cn
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property who Wilds or improve thereon. and who doessuchwork himselforthmugb his
own employees, provided that such Improvements are not (mended oro3'ered formle. If.
however, Ne building or improvement is mid within one year of comple0on, the Owner.
Wilder will have the burden of proving Out M did Out Wild or Improve for purpose of
sale.).
0 1. as Owner of 0he property am exclusively contracting with Imeruad conlrxcton no
construct Use projed (sec. 7014, Business And Profasstons Code:) The Contractors U -
cove law d. net apply to an owner of property who WIIds sur improves Norton, and,
who contacts for such pmjms with a comemearls) licensed Mention to the Cmnraawr.
License law.
❑ 1 om exempt under sec. . B R P C far thismason
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby uT,. under penaby of perjury om a( the following declua0ons:
mdfnnito -iuure fmW fte$ComPen-
1 ham and will maintains CenifrceCAseelf
then, u provided for by Section 3700 df the labor Code. for the performance of the
work for which this permit Is issued.
1 have and will maintain Whalers Compensation IosnSectionunce, "more by Se
3700 drum Iabm Code, for Ne performance of the wort for which this permit h issued
My Worker, Compensation Insurance artier and Policy number am:
GNer. /MAIv 7:e Policy No.: CZ DerM1S336 rr
CERTIFICATE OP PXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This scmmt need trot W completed If tis permit is fordne hundred dollen ($100)
or less.)
I certify that in the performmee or the work for which this Permit is issued, ) shall not
employ mypenOn in my mmneam as to became subject to the WOOmef Comp usim an
Iowa of California. Dam
Appllam
NOTICE TO APPLICANT: IL after maung this CeniRam of Exemption. you should
become subject to the Workers Compensation provisions of thd Latour Code you most
forthwith comply with such Provisions or this Permit Mall he doemcd mucked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that Otart is a construction lending agemy for the performarom of
the work for which this Permit Is issued (Sec. 3097. Civ. C.)
Lenders Name
1<ndaea Address
1 certify that I have read thi. application and some thu dee sheve mmrmadun is
correct I agree to comply with all city and county erdinwme, and tum laws relating m
building co sat tenon, and hereby authorize npreamudvce of this city to corer upon then
alrovcmentiumd Property for inspection purpoma
(We) agree to Live, immmniry and keep harmless the City of Cupertino against
liabilities, judgments, costs and expenses which may in Any stay accrue against sold 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
yLyplos�ezdw%t. --- g f'3/ 05'
Signuurt sial AppliaHAZARDOU Oahe
HAZARDOUS MATERIALS DISCLOSURE
WIII the suppliant Wilding orhadk h material
o(court aauhaptuwe eadous
u defined 0he o Municipal Code, Chapter 9.13. tori 0he HcJN mJ Safety
Section zss3u.)7
Code, 32(a)?
All roofs shall be inspected prior to any roofing material being installed.
❑Ya+
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building m:upant had equipment or devices which
I hazardous air contaminants As de0ncd by the Bay Arta Air Quality Management
all new materials for inspection.
District?
0Yea XL
I havered the huxdwsm dalsmquimmmuunderChapmri95oltheColifor-
iliaFlcalNBSafnyCade,SnNau]5503.J33J3 ad]5331.1 undershootNuif0he Wining
does net eumn0y have a mnme Nu It h my responsibility to sooty Ne aaupant of 0he
requiremems which mum W met poor to tstuarmc of a Certificate of Ocapury.
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner sur awhorimd a Dom