04090128CITY OF CUPERTINO
�,
BUILDING DIVISION PERMIT
�eCp,NTRA.C.O`,RN'U„MATION
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO 04090128
19503 STEVENS CRK ft 291
OWNER'S NAME:
PERMIT LSUR DATE
CUPERTINO HOUSING PARTNERS
909 AL
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITEC7VENGINEER:
BUILDING PERMIT INFO
BO ELECT PLO
O
LICENSED CONTRACT'OR'S DECLARATION
Job Description
I hemby affirm that I am licensed under pmvWons of Chapter 9 (commeaing
with Section TOM) arDlyl.up 7 of the Business and Professions Code.md my license Is
In mu wren and effm. gg8p
NEW CONDO - 1359 SQ.. FT. -
LiceClw Lic. M
Data Contractor O.m
ARCHITECTS DecLARAT101
1 unde� plane a1Wl h�ig.pudlic records
Lrented PmRssionel
DECLARATION
Oat
I hereby .(hero ben 1 em caumpl from Ur ConuactCo License taw for
I am exempt from
money
won. (Salton 7031.5. I.s, Bunts and Pmfeaaiunt Codd: My city w many
which re • m en aloe Wpmw, demolish. or repair any
which mqus
umomm
theAsurts t far such Conpermitu BICssignedsuumem
u e, %I. at me
that bits Issuance,atmm to the the canummr;LicenseLaw (CraPta9
(comm islicensedSectio( be Oa of
.Sq. FI. Floor Area
Valuation
Dbrionsser
(commencingwithSecdon7000)th Divisionr ofthceged exe and ProuWonsctae) of
157317
that be u esempl therthwn W Ua bass far da nim{ed exemption. My vlolatim of
that he Is
APN Number
Occupancy Type
Section 7071.5 by any applicant for a permit subjects the applicant to a c Ml penalty of
nil a. them 0w hundred &H. (5500).
❑I,otowt of the property,a empleyt withwegu u. CirroleeompetUm.
Required Inspections
will do I. row nt 7
ands:
Tessiohe do s
no Com amines kendended
and Pmfwaians Cade: The an Owner of
s apply
who Law tit not apply lf an owns of
q P
ws thereon. and
Property who thertm, and who data sahwmkhimself wNmuge Ms
employees, pmvlr(mpmwa
Own maamact IntendedaroRered fns .I,.
ane year of completion, the ownar-
sold a
Impmwmml )s hath
.,thprovided Improvement
builder, the building
builder will have Use buMen of proving that he did not Wild or Tmprow for purpose of
u a did
ask.).
❑ 1, as Owner of the property, am exclusively contracting with licensed enactment be
mmumn t that prejen (Sec. 7014, Business and Profoodons Code:) The Outnumbers U.
ante law does not apply be an owner of property who Wild, or improm thereon, and.
who concocts for such projects with • contractor(s) licensed pursuant be the Comranmrs
License law.
❑ l am satrap, under Sm. .B k PC fns this mare
wrDauWORKERS
COMPENSATION DECLARATION
1 hereby nUea under penalty of perjury am of the following declarations:
Icawnd will maintain a Cenificate of Conant a self -beam fns Wwkmr,Compen-
oo. a provided for by Section 37M of the tabor Code. far thd performma of the
k for which this permit la load.
1037',Oo
1 ban and will maintain Workers Compensation Wurance, u required by Section
of (he Labor Code, for the perform... of the woh far which this Permit Is Issued.
Worker's Compensation Insurance carrier and Policy number sm:
ier. 241C Policy No.: Cl
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(ibis scmlen td AW completed Rue permit Is rams hutdreddmlan(510(0
or Iam)
1 century that In the performance of the wort for which this permit is Issued. I Mall nm
employ any Nunn In my mannerha As be become subject to theworkma Compettlon
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If, arum making this Ceniflcam of &emptim, you should
become subject be the Worse, Compensation imenisiom of Ua Uhor Code, you muss
forthwith amply with mcb prevision or this permit shall be domed remind.
CONSTRUCTION LENDING AGENCY
I hemby affirm that them is a contraction lending agency for the performance of
the work (or which this permit Is issued (Sec. 3097, Civ. C.)
Lender's Name
Loader, Addw
1 certify that i hues read this application and sum that uc shout Information is
comm. I agme be comply with all city and aunty ordinance, and sum laws muting be
Wilding construction, and hereby authodm repmsenutim of this city 0 cater upon the
above-mendoned property for inspection purposes.
-
(We) aCrte m ave, indemnify and kap hatmlea the City of Cupertino against
IUNlities.Judgments,ensu and expenses which may In my way am= Against said City
In consequence of the Joko ng of this PCMiL
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCEREGULA ONS.
Re -roofs
Type Of Roof
Signature ofd ..Con Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applkronl Or future Wilding oceupantatom or handle haandous material
NO Municipal Code. Chapter 9.11. and Use Health and Safety
IM1111 d bytion Ur Cu(,.
cCode,25s3z(.)T
No
All roofs shall be inspected prior to any roofing material being installed.
❑Yea
OYU
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building =open, um equipment at devices which
mit haardaa air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑Yea
1 have mW the hmaNam materials requiremcns underChale 6,93ofthe Califor.
nice Health 6 Sat iyCede. Sections 15505,15533 ad 15534.1 understand that Ifthe Wilding
docs not cmrendy hex a wnmL that it is my responsibility m nutr'y the mount of Use
mqulmmcm which most be met prior be issuance of a certificate of occupancy .
Signature Of Applicant Date
All roof coverings to be Class "B" or better
Owner or au(hodmd agof