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CITY OF CUPERTINO
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`CONTRACTOR`INk T1QN_
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITN004090126
19503 STEVENS CRK 4 32
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
LLD909 ALMA STREET
005
E;
SANITARY NO, CONTROL NO.
(650)470-4700
ARCHITECT/BNGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lob Description
1 hereby affirm Nat 1 am licensed under previsions of Chapter 9 incontinencies
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with Section 7000) of Division 3 of the Business end Profesiom Code, and my license it
In rntl Corm o.d ercecL�
$Ole
NEW CONDO -1102 SQ FT
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ARCHITECTS SDEC LARATION
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Licensed Pm@tsional/Tfi�E
OWNER-BUIIDER DECLARATION
I hereby affirm that I am exempt from the CwasctaY. License Law for Use
following mason. (Section 7031.5, Business and Pmfesslont Code: Any city ar County
which require a permit te Conde(, after. improve. demolish, m mpair any structure
prior to its Nuance. aka rcmom the applicant for such permit an file a signed smemcm
that W is liccmed pursuant to the provisions of the Contractor's Umax Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70DO) of Division 3 of the Business and Professions Cadc) or
$127567
Nat he k exempt Wemfrom and the bask for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by ary appilca.t for a permit subjects the applicant to a Civil penalty of
not Come than Ew hundred doll. ($2100).
0 1. as owner of the property, ar my employee with wages as Weir sale eompenutlon,
Required Inspections
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will do the work. and the Nucer.is.1amused m offered far.ak(See. 70N, Budmas
and Propulsions Cads: The Conincmes License law doe not apply m an Owner of
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property who builds mimproves L erCoo. and wbodwa suchwark himselfarthrough his
Own employee, provided that such improvements K not Intended ma@lid fasale. If,
however, the Wilding m improvement is sold wird. am: year of Completion, the owner-
Wllder will haw the Wrden of proving that W did an Wild or improve for purpose or
sale.).
❑ 1, as owner of the property, am exclusively connecting with licensed conuacton u
contract that prolett (Sec. 7044. Business and Professions Code:) The Common's Li -
cents Law docs not apply to an owner of property who Wilds w improves tr mon, and
who contracts for such projects With a conmantor(0 licensed punas to the Conusctah
License Law.
0 I an exempt under Sec . B d: P C fm this reason
Owwr Dau
WORKERS COMPENSATION DECLARATION
I hereby anion under paudly of perjury arc of We following dechratioa:
1 have and Will maintain a cmdricau of Consent le u1r-imus for wmkces Compen-
utlon, As provided for by Section 3700 of the labor Code, for the performance or the
work for which this permit is issued.
❑ 1 haw and will maintain Weeks' Compensation Insurance, u required by Section
3700 of the Labor Code, for the performance or the work for which this permit Is Issued.
My Worker's Compensation Insurance Cartier and Polity ner are
umb:
Gnkr. /A3 --D%:- 7&-4z.Policy No.: C2?Lrais22i`vorai
CERTIFICATE OP EKEMPITON FROM WORKERS'
'
COMPENSATION INSURANCE
(This mclim wed Am W cmnplemd ifft pmmh Is frrone hundred dallun ($100)
ar least)
I sonify Nat in the performance or the work for which this permit is issued. I mall net
employ any person in any mantra As in become subject to the Wariaen' Cmnpassimn
Lam of California. Date
Applicant
NOTICE TO APPLICANT: If. net making this Octtifica , of Exemption, you should
become tubjcct to the Worker's Compensation provisions of the Labor Code, you mum
foMwiW comply with such provisions or this Permit shall W dammed maked.
CONSTRUCTION LENDING AGENCY
1 hereby aiErm We. Wen its construction radial ages for the perfameewc or
the work for Which this permit Is ksuW (Sec. 3097. Civ. C.)
Latices Name
Landers Add.
1 certify that 1 haw read this application and mm that the above mrormalan Is
Corson. I agree to comply With all city and county ominances and sure laws nhting to
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building construction, and hereby autho rte npmentaives of this city to enter upon the
ahove-mentioned property for Inspection purpomg
(We) agree to saw, indemnify and kcp bamlea the City of Cupertino against
liabilities. judgments, emu and expenses which may In any way accrue against sold City
Of the ANTUNDERRSTANling Of I
in APPLICANT C DS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE R�EGULATIONS
Re -roofs
Type of Roof
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Signature ofApplicapComrsuctor Date
HAZARDOUS MfQALS DISCLOSURE
Will the appllcmt or future Wilding oecupanuum or handle huardam materia
as dented by the Cupertino Municipal Code, Chapter 9.11. and the Heath and Safety
Code, Section 25532()7 �p
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All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant urea equipment or devices which
omit holavlaus air Contaminants as defined by that Bay Area Air Quality Management
all new materials for inspection.
Diurin7
❑ Ye
I have and the haardnut mac der requirements under Chapter 6.95 of ter (Slifer.
nit Hal" Safety Code, Sections 25505.25533 and 25534.1 undnsund mat If the Wilding
doe Out currently haw a earme Nat it k my responsibility to notal One occupant of we
requirements Which a=x 'or to u. .(a Catifcam of Ocmpucy.
Signature of Applicant Date
a ,e
All roof coverings to be Class 'B" or better
Owner mmlhmim ens Dom