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CITY OFCUPERTINO
BUILDING DIVISION PERMIT
1P, ONfiRACTOR1INF'O XT ON
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vPALISADE
BUILDING ADDRESS:
BUILDERS INC
PERMRNO04090123
19503 STEVENS CRK
OWNER'S NAME:
PERMIT L61M DATE
CUPERTINO HOUSING PARTNERS
LLD909 ALMA STREET
04/20/2005
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT(ENGINEER:
BUILDING PERMIT INFO
BLDG ELECTPLUMB MSCH
O
LICENSED CONTRAC TOWS DECLARATION
o
lb Description
1 hominy af0rm that 1 am licensed under PMVIJOSS Of Chapter 9 (commencing
P
with Section 70M) afDivWon 3 of the Businum and PMfessiuns Cade, and my license Is
In fell to. And arfem. A 38oy<,
NEW CONDO -1130 SQ. F.T.
lase L1.1
Lkense
Ato c Commcodr d tTJI�Nt Rs,�4s.�
ARCHITECTS DECLARATION
oris
I understand my plans shall be !!:d =mat
Licensed Profs onsl
OWN -BUILDER CLARATION
I hereby .(Bean that 1 m Law for the
Attempt from the Cssionsmo
:License c
followingmoan. (Section 7031.5,LARusmm, andCode: Any city armumy
1.
er
ms. der l li mpsig any muctum
which requires a permit cnwtrucL Wer, improve, denM
tE t
re for ouch permit m file seined statoment
prior to its issuance, p elan requires thovisio s Close
hecommoent;wiit pursuant in the of theCmmhman LlanAu law (ChaPkr9
Sq. Ft. Floor Area
Valuation
(that
(commencing with Section 7000) or Division 3 BeSegad exem Cade) or
$130808
basis f She al t on.Preloadny
Nat he ts exempt muefram and me bw4 for Sbe alleged exemption. Any= of
the
APN Number
Occupancy Type
Section 7031.5 by any applicant forS permit subjects me applicator o a civil penalty of
not mom Nm live hundred dollars (5500).
Q I, AS owner of Ilia property, or my employees with wages As their Sale compensation,
Required Inspections
will do the work and the Structure is not Intended m offered fonsale (Sec. 70W, BuainrSa
and Professions Cade: The Contractors Licawe Law dans not apply man owner of
property who builds or improws thereon. and whodoes such work himselfor through his
own employers, provided that such improvements em ant mu mded moffered for We. IL
however, the building or improvement is Sold within ane year of ecmpledan, the owner.
builder will have She burden of proving Wt he did not build or improve fm purpose of
Sale.).
❑ 1, As Owner of the property, am exclusively contracting with licensed o amain er, to
mnstmct the project (Sec. 7044, Bualnets and Professions Code:) The Contractor's Li-
cense law dans A tit apply to an owner of property who builds or ImpApwa poison. and,
who contacts for such projects with s cmuanor0) hoarded pursuant m the Comrsames
License law,
❑ I Am exempt under Sec . B & P C for this moan
Ownu Data
WORKER'S COMPENSATION DECLARATION
1 hereby.ffren under penalty of perjury ane of the following declarations:
hem and will sammudn • CoNRwta of Consent to self-iwum for WOrkrelCompan-
mtlm n. .m provided for by Section ]700 of tiro labor Code, for the performance of the
work for which ants permit is issued.
❑ 1 have and will maimaln Workers Compensation I===, As required by Section
3700 of the Labor Cade, for the performance of She wart far which this permh le Undo.
My Workers Compensation Immnna amu end Polity number art:
�c�
Gale A4.�'5%f J•LC Policy No:� OL>.•sdlit/ a�
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
ffIsis Auction reed Amt be complemd if tic permit is for.. bundmd doll. (S 100)
or Ins.)
1 certify Aha, in me performance of the work, Into which rola permit U Wood, I WJI nm
employ any person in any Answer an As, At Accord Subject to the Woheri CompcmCon
Laws of California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this Cctalicam of Exemption, you Would
become subject to the Worker's Compensation provisions Of Om Later Code, you must
forthwith comply with such provisions at this permit shall be deemed mucked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that mem luconstructin t lending agency 1'nr the marormance or
the work for which this permit B imed (Sec. 3097, Civ. C.)
Lenders Name
Lenders Addrwe
1 certify that I haw mad this application and sum that the &how Information is
"
cones 1 aims to comply with JI city and county ordinanms and slate law relating to
Wilding construction, and hereby author= representative of this city Monte, open the
above-mentioned property for inspection Purposes
(We) agree to sew, indemnify and keep harmless the City of Cupcnino against
Ilauiluies, judgments.ewts and exi mow which may In my way amTue against Said City
I. c.nwgnenco of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:S4��&aH Date
SOURCE EGULATIONS,
�r's I - Al-
/ii'L ems
Re -roofs
Type of Roof
Signature ofA�yy trusher DAM
IAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle haam ous material
&s defined by the Cupertino Municipal Code, Chapter 9.13. and the Health and Safety
canis, secY.2sa:an J
All roofs shall be inspected prior to any roofing material being installed.
❑law Na
If a roof is installed without first obtaining an inspection, I agree to remove
Will the Applicant or role. 3RIlial occupant use equipment or devices which
hvaNnw Sir contaminants AS delimit by dm Bay Arca Air Quality Management
all new materials for inspection.
tanin?
❑Yes
I haw read me husrdnus maurials requirements under Chapter 695 of the C.14.1-
.L Fkalth & Saresy, Code, Seem= 23305.25533 and 75534.1 undersuM tins ifthe Wilding
does not currently haw a tonam, than it u my responsibility to Amity the mcupset of She
mqutmmemts which max be met prior to issuance of. CenlBwM ofOccepanry.
Signature Of Applicant Date
ti�J
All roof coverings to be Class "B" or better
Owner ar wthodud agent Date