04090121r
IL
CITY OF CUPERTINO
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INF.O.RMATTyO
BUILDING DIVISION PERMIT
UN'L12ACTQR
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITNO.04090121
19503 STEVENS CRK 4 120
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
04/20/9.005
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Descri tion
Net l am limed under previsions of Chapter 9 (commencing
I hereby Airline m
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with Section 7000).F Division 3 of he Biomass ane Professions Cods, end my license Is
Inrc
111 faeand effut, g,� a y,6
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NEW CONSO-1487 SQ. FT.
LicenseClassI
Data n Comment P Lr .4fir— .d.a
ARCHITECTS DECLARATION
I undo plans andl he ublic arm
L.iceWed Profmconal
OWNE-BUIWER DECLARATION
I hemby Arbon that I em exempt from Ne Contractor's License Law for Mme
following Ratter. (Sudan 7131.5. Bud. and Profession Code: My city or rnumy
which requires a permit to contract. mese improve, demalleh, ar repair my suracare
prier in in imunce. also requires the epplicmt forsueh permit m file a sigmd summent
that he is licensed Vermont to the provisions ofthe Coruscates Umar Law (Charter 9
Sq. Ft. Floor Area
Valuation
(commencing with Sudan 7000) of Division 3 of the Business W Professions Cade) or
17 213 5
Out he is exempt therefrom and the basis for the alleged exemption. Any vlaladon of
APN Number
Occupancy Type
Section 7031.5 by any Applicant for a permit subjects the applicant to a civil penalty of
not mom than It hundred dollars ($500).
❑ 1, u owner of the pmpeny, a my employees with wages m their mlea mpenudon,
t1620084.00Required Inspections
will do the wad.md the wrctae 4 not Intended reoffered fomlo(Sec. 7041, Business
And Profemiom Cada: The Ceremonies Limnm Law does not Apply to an canner of
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property who builds or i mprows themon, and who does such work himself or through his
own employees, provided that such Impmwm"U are not intended croffered formic. If,
however, the building or Improvement is mid within am year of completion, the owner.
Wilder will have the burden of proving quit he did not Wild or Improve for purpose of
sale.).
❑ 1, as owner of Ne propeny, am exclusively conumting with licensed contractors to
construct the pmjea (Sec. 7044, Business and Professions Code:) 77th Conuctoes LL
cause Law does not Apply to an owner of property who builds or improves 1heRm. and,
who contracts for such projects with a conummr(s) licensed pursuant to the Conuacmes
License Law.
❑ I am exempt under See ,B Ar PC for this Raton
Owmr Dam
WORKER'SC•O�MPENSAT70N DECLARATION
I bereby affirm under penalty of perjury ane of qR fallowing declarations:
"
hero and will maintain a Cenifiam of Consent to self -Insure for Worker's Camper'
-tion. m provided for by Secdan 3700 of me labor Code, for me performance of Ne
work for which this permit Is imud.
❑ 1 hove and will maintain Workers Compensation Insumnce, a required by Section
3100 ofthe Ubw Code, far qto pemfsrmance of Mm work for which this permit lslmoeJ.
My Worker's Compensation Insurance carrier and Policy number em:
_
Cartier. JV43eSii! 711o,C Policy No.: 42.2 rn2§---WT
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
[rho mmtinn wed not bemmpleted Hthe permit Is forest, hundred dollars ($10)
or less.)
1 certify Net in the performance of me wad far which this Permit Is laved, I Nall not
employ any person In my manneran As to become subject to the Workers'Compecation
Laws of California. Dam
Applicant
NOTICE TO APPLICAM) IL after making Na Cenifinm of Exemption, you should
become subject b the Walker's Compensation Provisions of the labs Code. you moo
forthwith comply with such provisions or this permit shall W deemed Rooked.
CONSTRUCrION LENDING AGENCY
1 hereby affirm ft gmrttss caatreNnn lending agency for the performance of
the work for which this permit Is ismcd (Sec. 3097, Civ. Cd
Lemices Name
Lender's Addle..
I malty that I haw mad this application and sum Net the above Infommiu Is
correct. 1 Agree to comply with all city and county moimmes and sole laws mlalms to
building consuuction, and hereby authorine representatives of Nis city to cram upon the
ahovo-mentioned property for Inspection purposes
(Wc) agree to cow, indemnify and keep homeless Ne City of Cupertino against
liabilities, judgments, costs and expenses which may in my my &=am against Wit City
In ertfyueace of the gMting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Type of Roof
Sigadum of ApplicantC rotor Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future Wilding oaepmt more or handle huudoW material
a defimRd by f Cupemno Municipal Code. Chapter 9. 12. and the Health and Safety
We. Section 25532(x)7��`�////rrss
All roofs shall be inspected prior to any roofing material being installed.
[3y"
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
I hAWdoos air cone ainants As dcened by Ne Bay Area Air Quality Management
all new materials for inspection.
District? Y "—
❑Yes
I have mad the haremnusmaterials requirements under Chapter 6.95 of the Ctlifon
nes Health ✓k SNctyCodc, Seetions 25505.25533 soul 25534. 1 understand Not irtm [wilding
Jus not currently haw a mnmL Mut It is my RapoW billty to md'y the areupant of the
mquirements which must be ren . to.As ofocraft mor Occupancy.
Signature Of Applicant Date
4.2/
All roof coverings to be Class "B" or better
Owner aadhorim a ant Dom