04090124L
4
CITY OF CUPERTINO
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TN'F'ORMATIO I
BUILDING DIVISION pEjjlyjj'r
xCONTRACt6 .• ,;
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BUILDING ADDRESS:
PALISADE BUILDERS INC
Pr'tMITNo'04090124
19503 STEVENS CRK 267
OWNER'S NAME:
FOUAT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
E;
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONDIACfOWS DECLARATION
Job Description
P
1 Aeroby of na Wt I sm licved orator provwG oor Chapter 9 (Commencing
with Section 70M) of Dlvidon 3 of Ne Beat. tib Pmrewons Cade. and my Ikons u
ureem Rv80N6
NEW CONDO - 1359 SQ.FT. -
eormandefreCLd Lk.I
Data sem—ContractorAC ` 'W= eh'dams.:;
ARCHITECTS DECLARATION
1 underwnd my� plant that he u�blic rte
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby AfNm that I am exempt from the Canuacmr's License Law far the
following mason. (Section 7031.5, Business and Profoolons Cade: Any city or county
which requires a permit to cma,uct, eller. Improve, demolish. m repair any amemm
prior to its issuance, alae requires the applicant forsuch permit to hie a signed statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the pnvislon, of the Conlmcwrs License Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Prokaslons Code) or
$157317
Wt he Is exempt aremfmm and the bub for the alleged exemption. Any vialmlon of
APN Number
Occupancy Type
Scct1m 7031.5 by any applicant for a permit subjects the applicant o A Civil penalty of
rte Come than five hundred dollars ($500).
0 I. As owner of Ne property, or my employe with wages As their sole compensation,
9t620084.00
Required Ins ections
e,
will do the wok, and the structure b oat imendedoranertd forule(Sec. 70 .Buri eta
Code: The Commerce, Licerue rot law dons apply In an awnsof
and Professions o
9 P
property who Indicator improves thereon, and who daa ouch work himse Ir or through his
own employees, provided Natsuch Improvements Am not intended "offered forsak IL
howewq the building or improvement is sold within one year of Completion, the amer.
Wilder will have the harden of proving that he did nm build or improve for purpose of
sale 1.
0 1, a ewer a the property, am exclusively contracting with licensed ammoucNn m
consumer the project (Sec. 7010, Business and Professions Cade:) The Contractors U.
cense law does not apply to an owner of progeny who bind, u improw Nemec. arui.
who contracts for such Projects with A amntracter(s) li«Ged puraunt mthe C.mosc oes
Liceve law.
0 l am exempt under Sac . B k P C for this mason
OwnerDare
WORKERS COMPENSATION DECORATION
I hereby affirm under penalty of perjury arc of the following declarations:
haw and will maintain • Canifiate of Conant m relf-WAM fa Wor9ersCompen-
n, ss provided for by Section 3700 of Ne labor Code, for Ne performance of the
for which this permit is Issued.
137.0()ordarc
law and will maintain Workers Compensation Insurance, u required by Section
Mbar Cade, forNe performance of Ne wort for which Nispermitis issaod.
Workers CorpensWon Insurance cmier and Policy number are:
ier. NI il.)/7%: G Poliry No.: C.2006OZ6J.136 S
CECATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
rMis section need not be completed Hthe Permit I$ feone hundred dollara (SIM)
or les,.)
1 certify that In the performance of tho wok for which this permit b Issued. I shall not
employ any person In any manner an As to became subject to the Workers'Compensa0on
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. one, making this Cenifleate of Exemption. you should
become abject a the Wokeri Compensation provisions of the labor Code, you most
forthwith amply with such provisions "I. Permit shall M deemed rewked.
CONSTRUCTION LENDING AGENCY
"
I hereby,ifual that Nem is a Construction lending.gene y for the performance at
Bre work for which this permit Is ismad (Sec. 3097, Civ. C.)
Landers Name
.
Lenders Add"•••
I certify that I haw rad this application and mm 0w the above inrwmatim Is
cone s. I agree to comply with all city aha County ordinuuss and Awe buss relating m
Wilding construction. and hereby authorize representatives of this city N enw upon the
¢bow -mentioned property fm inspectim purpose.
(We) agree N saw, indemnify and kap harmkas Ne City of Cupenlm against
liabilides, judgmcets.eau aha expense, which may In any way.me aouAJARAs d Cly
mconassfunceofulagarenti
APPLICANT UNDERSTANDS AtND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type Roof
ae L — 11 21.0
-
Signaturear Appli uCmtnmG Date
HAZARDOUS MATERIALS DISCLOSURE
of
Will the applicant or future building oceupant store or handle huardous material
As donned by the Cupertino Municipal Code, Chapter 9.13, and the Health and Safety
Code. Sectio. 25532(.)7 '(
All roofs shall be inspected prior to any roofing material being installed.
0YG zl+
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant Ge equipment or devices which
emit haGAnua air contaminants u defined by Ne Bay AMA Air Quality Management
all new materials for inspection.
District?
❑Yea
I haw mad the hasardausmatedals requirements under Chapter 6.95 of the Celifor.
nu Health G Safety Codc,Smd=25.505,25333 ad 25534.1 undermnd thuifthe building
daa not currently haw a ¢nano that it is my responsibility s nadl'y the axupam of Ne
mquimmcna which must k numprior m issuance of. Ccnincate of capancy.
Signature of Applicant Date
--O
All roof coverings to be Class "B" or better
Owner or author' cool ' Doc