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CITY OF CUPERTINO
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BUILDING DIVISION PERT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO04 090 13 1
STEVENS CRK 4 319
19503
NER'S NAME:
PERMIT ISSUE DAM
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
n4/2c)/2nnc;
E:
SANRARY NO. CONTROL NO.
650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
ILDO ELECTO PLUMB MECHQ
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LICENSED CONTRACTOR'S DECLARATION
Job Description
P
1 Twenty affirm that I am Ii= under proWgoan of Chapter 9 (commencing
with Section 7008) of Division 3 o(the Bugwaand Pro(cegons Cade,and my license is
rwuome anderceet. D
M'0'
NEW CONDO - 1025 SQ.. FT.
LkenO CI Lie. N
Dem Contractor AlaArt "alcm
ARCHITECT'S DECLARA ON
I undcrs rad my piece shall used u public records
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Licensed Pmulmaimad / <�
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Conlncmr's License Law for the
following mason. (Section 7031.5, Business and Pmrcssione Code: Any city or county
which requiros a permit m construct, almr, improve. demolish, or repair any someone
prior m its issuance, also requires the applicant for such permit to file reigned statement
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to The provisions of the Comment's Umme Law (Chapter 9
(commencing with Section 71100) of Division 3 of the Business and pretensions Code) or
$118654
Out he is ecompt therefrom and On basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Sectnn 7031.5 by any applicant for a permit Objects the applicant to a civil penalty of
not mote than live hundred dollars (5500).
❑ 1, ou owner of the property, or my employees with wages as their Ole compensation.
Re aired Ins actions
will do the work, and Tees,meaune in not intended Or offered fosanle sea. 7044. Business
and Prorasslons Code: The Conbaemrs Limo law dace not apply m Oman, owr of
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property who builds or improves Thereon, and who does ouch work himself or through his
own employees, provided rhatanch improvements arc not managed mnaercd for We. if.
however, me building or improvement is Old within one year of completion, the owner.
Wilder will have the burden of proving that he did not build or improve for purpose or
.te.).
O 1, as owner of me property. am aclusively contracting with Reasons! members, to
construct the project (Sec. 7044, Business and profession Code:) The COMMKWI's Li -
ave law does not apply to an owner of property who builds or improves, themon, and
who contracts for seen projects with a conVIIlans) IiaMed pursuant W one ConmRto's
License Law.
❑ I On exempt under Sea .B@PC for this reason
Owner Dau
WORKERS COMPENSATION DECLARATION
I hereby affirm under porosity of perjury am of the following declarations:
1 have and will maintain a Cmdfram of Cement m ul6imum fm Wa geraCompen-
dw performance of the
iNon, an provided for by Section 3700 of we labor Cade. ran ma
work for which oris, permit is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, an required by Section
3700 of ren Labor Code, fm the performanm of Tee wank for which this permit is ksmd.
My Workers Compensation Instincts artier and Policy number ane:
Cartier: Policy No.:
-
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(fhlss Aden need ant mcompleted Ifthe Mrmilis fmone hundred dollars(SIM)
nrinss)
1 certify that in On performance of the work for which this pemab is Issued, l shell not
employ any person in any Mannar an an to become Object in the Workers' CompensNon
Laws or California. Dam
Applicant
NOTICE TO APPLICANT: If. after making this CcrtiOam of Exemption, you should
become subject to the Worker's Comp ountion provision of Ore Labor Code, you must
forthwith comply with such provisions or this permit shell be deemed revoked.
'' CONSTRUCTION LENDING AGENCY
I hereby afnrm mat mem is a construction lending agency for the performance of
the work fm which this permit Is Wood (Sec. 3097. Civ. C.)
Lenders No
Landers Add.
j I certify that 1 have mad thin application and sum Test the above termination is
e cortecL 1 agree an comply with all city and county ordinances and sum laws relating In
building construction, and hereby anmodse reposomme Ivo, of thin city to enter upon the
above-mentioned property for impeNon purposes.
( (We) agree In saw, indemnify and keep homeless the City of Cupertino against
i liabilities,judgments, costs and expenses which may In any way acme agamal sold City
in consequence of the granting of this permit.
t APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
�Lua �_ilL,
Slgnmumof Ap cmT on Dam
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building mcupantatore ahandle hazardous material
an dcOned by me Cupertino Municipal Cade. Chapter 9.12, and the Health and Safety
Code. Section 25532(.)?
All roofs shall be inspected prior to any roofing material being installed.
❑Yos "
If a roof is installed without first obtaining an inspection, I agree to remove
Will Nc applicant or future building Occupant use equipment or devices which
It hmerdnus air contaminants as defined by the Bay Arca Air Quality Management
all new materials for inspection.
Diuricl?
❑Yea'
1 have mad the harardous materials requirements under Chapter 6.95 of the Califor-
MaHealth 6SarctyC%w. Samoan 23505.25533 saw 25534. I undcrstsnd met if the building
dean nut currently have a nnan4 that it 4 my responsibility to notify the oeeupanl Of the
rcquimmenu which mug be met prior w issuance of. Comficam of Occupancy,
lgnature of Applicant Date
d
All roof coverings to be Class "B" or better
Owner or euthod bent Dom