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CITY OF CUPF.RTINO
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO. 04090172
OWNER'S NAME:
CUPERTINO HOUSING PARTNP.Rq
ging ATMA STREET
PERMITISSUBDATE
•
SANITARY N0.4/2 CNTROL N0.
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby affirm Net I am licensed under p nvWon. of Chapter 9 (commenting
with Section 70M) of Division 3 of Me Business and Proressiuln Casio; and my license is
I. full force end effen.
JR6.n4
NEW CONDO -1478 SQ. FT.
Licensec1 _e Lb..# tort dt�
ARCHITECTS DECLARATION
I mdcrammi my plan still. c records
Licensed Profasi
OWNER -BUILDER DECLARATION
1 hereby affirm'bar I am exempt from Ne Contractor's License Law for the
following moon. (Section 7031.5, Business and Pm(culom Cole: Any city or aunty
which requires a permit to ...I=. alur. Improve, demolish, or mpair any almctu ,
prior In its issuance, also requires the applicant for such Pcrmi, to file a signed statement
Sq. Ft. Floor Area
Valuation
that he I. licensed pursuant In the provision. of the Contractors U.. law(Chapter 9
(commencing with Section 7") of Division 3 of the Bmuess aha Profesalon. Code) o
Met he Is exempt therefrom and the basis for the alleged exemption. Any vlOhdan of
APN Number
Occupancy Type
Section 7031.5 by any applicant fm a Permitsubject, the applicant to s civil Penally of
out mom than five hundred dollen ($5001.
1, as Owner Of the pmpeny, or my employees with wages u their sole compenYtion,
84 - J Required Inspections
will do the work,and thesuocture 1, not intended oroaeud forlac,(See. 7044. Business
and Prafeulm. Cade: The Commerce. License Law does onl apply to an owner of
property who bulli.orimproves hemon,and whodoeuuch work hlmselfor through his
Own employees, provided that such Improvements us not Intended reoffered for sale. IL
however, the building or improvement is sold within we you of compledon, the owner-
wildcr. will have the burden of proving this he did not Wild or Improve for purpose of
sale.).
❑ 1, as Owner a the property, am exclusively contracting with licensed commcorm to
construct the protect (Sec, 7044, Business and Professions Cade:) The Cmuumr's Li.
cense Law time not apply to an owner of progeny who Wilds or Improves themon, and,
who contracts for such pmjecu with a c9rommor(s) licensed Pursuant o the Contractor's
License Law.
❑ l am exempt under sec. , B & P C for'bia mases
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby afRrm under penally of perjury one of IW following declmllan.:
I be. and will mtnuin a CenlOato of Consent self -Imam, fm Worker-Compem-
o performance o('
anion, u provided for by Section 3700 of he IaWr Code. fm tW
work for which this permit h issued.
❑ 1 have and will maintain Worker's Compensation Insurance, u required by section
311 of tic labor Code, for Ne performance of the work for which this permit is iumd.
My Worker's Compensation Iosurence artier and Policy number am:
Cartier, A4747a'C 7' policy No.:C2OA*72 -03
'
CERTIFICATE OF E%EM MON FROM WORKERS'
COMPENSATION INSURANCE
(Thu rection need not to completed lftW permit Is fimone, hundred dollan(SIM)
or )esa)
1 certify the, In the performance of the work for which this Permit Is issued. I that) not
employ anypersan in any mannersn as to berome sabjectto the Workere Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT. IL after making this Certificate of Exemption, you should
Wetness Subject to the Workers Compensation pmvisims of the Labm Code, you must
forthwith comply with such provlton. or this Permit bell W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 Wroby affirm that them is a connotation lending agency for tic Performance of
Me work for which this permit Is Issued (Sec. 3097. Civ. CJ
1 lenders Name
lender's Add.
I 1 cenify that I have read this pplication and sou Nn the sive ufornatlon is
h cornea I agme to comply with all city ad county on inances and sum saw relating to
Wilding construction, and Wmby authorize mpremntsOves of this city to enter upon the
( alcove -mentioned properly for Impension purpoua
(We) agree in saw;, Indemnify and keep hsrmleas the City of Cupertino against
i Ilabilitu.judgments, emu and expenses which may In any my accost, against laid City
in consequence of the Starling of this permit.
i APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL -POINT
Issued by:9 Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
'
Sigma rim of ApplicantConuactor Data
DISCLOSURE
HAZARDOUS MAT&KALS
Will he appllant ter futureW Ilding oecupmUtme or handle huardoosmaterial
u de0ned by he Cupertino Municipal Code, Chapter 9.11. and he Health and Safety
italicWe,seclian z5s3:(.)7
All roofs shall be inspected prior to any roofing material being installed.
❑Yes
If a roof is installed without first obtaining an inspection, I agree to remove
wen the applicant r futum Wilding Occupant use equipment or devices which
It hammous alr contaminants u defined by the Bq Area Air Quality Management
all new materials for inspection.
Isuicl7
0 Y0 fay
I have mad the Wraesm'mri'Iercqultemenu under Chapurh.95afthe Cellfor.
nia Health & Safety COde, Secdont25505,25533 and1553/.I understand half ties Wilding
does not currently have a tenant. that it is my responsibility to notify the meupant of the
requirements which must W mel prior en Issuance oil Certificate orOccuPancy.
ISignature of Applicant Date
All roof coverings to be Class "B" or better
Owner urauthr'. t Date