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BUILDING DIVISION pE]jMj'j'
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BUILDING1OD77`0STEVENS CRK # 201
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PALISADE BUILDERS INC
PFRMITNo.O409O127
OWNER'S
IiPERTINO HOUSING PARTNERS
LLD9O9 ALMA STREET
PERMIT ISSUE DAM
04/20/2005
E:
SANITARY NO. CONTROL No.
6503269300
PALO ALTO, CA 94301
ARCHITEC rENGINEER:
BUILDING PERMIT INFO
NEW CONDO -1102 SQ. FT.
BLDG ELECT PLUMB MECH
L-7 O O
LICENSED CONTRACTOR'S DECLARATION
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Job Description
I Mmby ,films that I am licensed under proWaions of Chapter 9 (commencing
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with Section 70(10) of Division Sof the Businsomand Profcaiom Code, AM! my Iiceae is
in full tome and eRect.
Licence CI uc. /
v
Dam Contractor
ARCHITECTS DECLARATION
l undeMyplw shall sed ubiir, ma'prds
Licensed Pmrchubmul
OWN 0BUIL.DER DECLARATION
I hereby affirm that I are, exempt from the Contractors License Law for [be
following mason. (Saban 7031.5, Business and professium Cade: Any city or county
which requires a permit m construct. alms Improve. demolub, or repair any amCtum
prior m its issuance, also requires the applicant forsuch permit to file a signed stsmmcm
that he is licensed pursuant to the provisions, of the Contractor's ldccnw Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section 70M) of Division 3 of the Business and I'Mraainns Code) or
that he W exempt themfram and Ne basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant fora Permit subjects Ne applicant to a civil penalty of
not mart than Eve hundred dollars (5500).
❑ 1, An owrmr of the property, or my employees with wages an their nom Compensation,
Required Inspections
er
will do the work. AM the euunum is out or offered rorsale (Sec. 7044. gasirw••
and Projections Cod.- The Courn,te rs Liame law Cees no apply to an nwoeof
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property who builds m Improves themon, and who does such work him alfor through his
own employees, provided that such improvements are not intended or offered for sale If.
however, the building or Improvement in mid within one year of aempletion, the owner
huildec will have the burden of proving that he did Am Wild or Improve for purpose of
sale.).
❑ 1, as owner of the Property am exclusively contracting with licensed Conuxctom in
construct the project (Sec. 7W, Business And Notations Cade:) The Contractors U.
cove Law does not apply to an canner of property who builds or Improv daemon. and,
who contracts for such projects with a conmctor(n) licensed purmant to use Contractors
Licence LAW.
❑ 1 am exempt under Sec. . B k P C for this mann
Owner Dam
WORKER'S COMPENSATION DECLARATION
1 hereby &Mmt under penalty of perjury one of the following declarations:
1 have and will maintain aCeniEwte of Consent to self•Wum for Worker. Compere
ation. An provided for by Section 37M of the Labor Cede, for Ne performance of the
work for which Nin permit is issued.
❑ 1 ban and will maintain Workers Compensation insurance, no required by Section
3700 of dao Labor Cede, for the performance of the work for which this permit is Wan&
My Worker. Compensation Iommnce carrier and Policy number am:
Carrier. dsa0.ui7,G TS, ePolicy Nest tx1D0,593a]
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This section seed not Wcompleted If the Form[[ Is intone huMred dellen (SI00)
nr last.)
1 cenify that In the performance or the work for which this permlt It hand. I stall not
employ any person in any mannerm as to become subject to On WOrkcrs'Compcmauon
Laws or California. Dam
Applicant
NOTICE TO APPLICANT: If, after making this Certificate of Exemption, you should
become subject to Ne Workers Compensation previsions of the labor Coda you meet
forthwith Comply with such provisions or this permit shall be de m x! revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affrm that dem In. conswction lending agency for the performance of
the work for which this permit is imued (Sec. 3197, Civ. C.)
Lenders Name
Lenders Address
I certify that I haw mad this application AM stem Chat No abow Information is
'
COMM. ) agree to Comply with all city and county aNimmes and show law minting to
building construction, and hereby Authorize mpresentativ of this city to COW upon the
ahavo-menaned property for inspection purports.
(We) agree to ave. Indemnify and keep harmless the City of Cupertino agaWt
Ilabilitiea.judgments,coats and expenses which may In any any accme agalnstaaid City
In consequence often granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS./
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¢f� �r� -2/-o.5—
Re -roofs 07
Type of Roof
Sqn ort of Apish onuactor Data
AZARDOUS MATVUAIS DISCLOSURE
Will the applicant or to= building oceupmt aom orhaMle handem material
u defend by um Cupertino Municipal Cade. Chapter 9.13, and the Health and Safely
Code.Section x553xra)7 ^ /
All roofs shall be inspected prior to any roofing material being installed.
❑Yes Aja
If a roof 1$ installed without first obtaining an inspection, I agree tO remove
Will the applicant m✓rutumm building Occupant use equipment or devices which
mit hazardous air contsminanu a defined by the Bay Area Air Quality Management
all new materials for inspection.
District? /
❑Yes
I have mud the haaNnusmamrialf requirements under Chapmr6.95 oHne Califon
Mia HallhB SafetyCodc, Swfi=25505,25533 md25534, I undersand daulrthe building
does not currently haw a mnmq that it is my respomOiiny to May use occupant or the
rcyuiremenu which mustet poor to laaence of a Certificate of Occupancy
O
Signature of Applicant Date
All roof coverings to be Class "B" or better
owmr nr.mneri> d agent Date