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CITY OF CUPERTINO
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CO TI A
BUILDING DIVISION PERMIT
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BuaDiNG ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.Q 4090122
19503 STEVENS CRK ff 220
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
n4/2n/2ooc;
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHMCT/ENGINEER:
BUILDING PERMIT INFO
t
BLDG ELECh PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
oerP
mby ,fib t 1 licensed under provistmta of Chaptef 9 (ammca
1 bem Wam im,
with Section 70fsf ofDh,hMe 3 ofd. Buainw and Professions Code, and my license is
mrullmmeandeffceL �saoy6
NEW CONDO -1487 SQ. FT.
Licenl Lie.p
Do.-!!Omuxctor , ]AM: ,: o
ARCHITECTS DECLARATION
Iundersand my plana a I gmlued u ash cpr&
CJ
Luumod professional
0 NER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conuamor's License Law for the
following mann. (Section 7031.5, Business and Professions Cade: Any city or county
which requires s permit to cmanet, altar, impram, demolish, or repair any Imcmre
prior to its issuance, also requires IIM applicant foranch permit to file a signed statement
that he is licensed pursuant to lW provision of the Contractors Lianse Law (Chapiu9
Sq. Ft. Floor Area
Valuation
(commencing with Secdan 7000) of Division 3 of the Business and Profession, Code) or
17 213 5
Nat he is exempt therefrom and de, basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Secden 7011.3 by any applicant for a permit subjects the applicant to a civil penally of
not more than Rw hundred dollars (S500).
❑ I, as owner of die property, or my employees with "gas Is their sok cams masllan,
Required Inspections
e
will do the work and im nnum b,aninmaded oroffered fouale(See. 7044, Business
and Profea11 Code: The Committees Lt.. Law doss not apply m m owner of
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property who buildsser impmvea thereon, and who does such work himselfor d rough his
own employees, provided that such improvements arc not intended araQered for ale. If,
however, the building or improvement Is mid within mm year of campledon, the owner -
builder will ham the burden of proving Nal M did set Wild or impmw for purpose of
ale.).
❑ 1, Is owner of the progeny, am exeluimly contracting with licensed conuacton to
construct the project (Sec. 7046, Business sad Prolbustan Code:) The Contractors LI-
ceve law does not apply man owner of propeny who Wilda or improves memon. and
whocomeacts for such pmjecm with a eonuscmr(s) licensed pursuant to the Cnnbamr'l
License Law.
❑ I am exempt under Sec. ,B&P C far this mann
Owner Dam
WORKERS COMPENSATION DECLARATION
I thereby &farm under penally of perjury one of the following decimations:
-
haveand will maintains Certificate ofC....1 to self-insum fu Worker'sCompen-
action, Is provided for by Station 3700 of tbe labor Code. for the performecee of the
work for which this permit is laced.
❑ I ban and will maintain Worker's Compensation Worsen, as required by Scction
1700 of the Labor Code, for the performance of the work for which this permit is lamed.
My Worker's Compensation Inm once carrier and Policy number are:
Carrier. SsuC Policy No.:C1 Oft i:�S.ets
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(771s, ..it. need nor W complcwd If tbe perm, Is forone hundred dollar ($1010)
or less)
I certify Not in the performance of the work for which this permit is Issued. l shall not
employ any pcomn In any mannerm Is In became mbjwt to d. Wafker3 Compensation
Laws of California, Dam
Applicant
NOTICE TO APPLICANT: If, after making this Cenince c of Exemption, you should
become subject to the Worker's Compensation provisions of the Labor Code, you must
roMwith comply with such provision or this Permit shall be decmrA revoked.
CONSTRUCTION LENDING AGENCY
I hereby ,farm them dere is a cmrstmclinn lending agency for the performance of
the work for which this permit is issued (See. 3097, Civ. C.)
Lender's Name
Landers Address
1 certify that I haw and this application ad seta that the show Information is
'
torten I agree to comply with all city and county ordinances and sum laws relating to
building construction, and hereby authodm mpmsenutivu of this city to enter upon the
above-mentioned property for irupec ton purposes.
(We) agree to new, indemnify and keep harridan the City of Cupertino against
liabilities, Judgments. carts and expenses, which may in any way acme against said City
in concapence of the s rmit.
APPLICANT UNDERSTANDS Aof rND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
c C
e—
Slgnlurcof Appheab nball Dam
URE
H RDOUS MATERIALScupast
Type of Roof
ce or material
ser handle
Will the applicatufoaum building Co
e. Chmlamm
Healthy
a de0ned by the Cupertino Municipal Cade. Chepmr 9.12, and the Health a0 Sa(cty
de. Section 25532(e)? ` /t
All roofs shall be inspected prior to any roofing material being installed.
❑ Yu 7921u
ith
- If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant at future\building occupant era equipment or devices which
aardaus air conumimnts as refined by the Bay Area Air Quality Management
all new materials for inspection.
uicl?
❑Yea
1 h ave and the hvardaws makrkls mquimmenu undo r Chap mr d.95 of the Cali for-
maHca,h&SafctyCodc,Sccdon25505.25533 mu125534. 1 unbentand thelifthc Wilding
dos, not currently haw a knot, that It k my responsibility m notify tbe occupat of the
requinmenu which mnlbe met br laiasuaceafa Ccoificakaf Occupancy.
Signature Of Applicant Date
data
All roof coverings to be Class "B" or better
Ow@oris d agm Data
ner ser m