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CITY OF CUPER'fINOk,
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BUILDING DIVISION PERMIT
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RUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT N
54090209
A
PERMFr ISSUE DAIS
OPPERTING HOUSING PP.-RTNERS
909 ALMA STREET
___nA.Lan /2
SANITARY CONTROL NO.
ARCHITE.0 (ENGINEER:
BUILOINO PERMIT INFO
BLDG ELRGT PLUMB MP.CH
LICENSED CONTRACTORS DECLARATION
lob Description
I hereby am. Ow 1 am licensed under Provisions of Chapter 9 (.am ... is,
with Smile. 70(1)) of Division 3 of the fashion and Profculua Code. end my license is
in full force and effectR04G
Uesna b.a— Lis.g
NEW CONDO - 1580 SQ. FT.
-
Data Comncmr u"SA0 ae _
ARCHITECTS DECLARATION
I understand my plena all he unit in public records
Licenad Professional
OWNS ILDER DECLARATION
I hereby affirm 'hot 1 am exempt from the Contractor's License Law for the
following Mason. (Section7131.5, Business and Professions Code: Any city or county
which requires a permit to ..tact, Mur, Improve, demolish, or repair any almctum
prior to in luuance, ala requires the applicam for such permit to rile 4 signed statement
Contractor's Limon Low(Chapter 9
Sq. Ft. Floor Area
Valuation
that he is lloonsed pursum to the previsionsofthe
(commencing with Section 7000) of Division 3 of tbe Business And Profusions Cade)at
00
Ban he B eaempt therefrom and dm bub for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant rat a permh subjects the applicant to a civil penally of
not mom Nan rise hundred dollen ($500).
❑ I, as owner ofthe property, or my employes with wages As their sale compensation,
3162008400 Required Inspections
wllldo the work, and the smuc'ure isootheanded moRered rouele(Sm. 7044, Business
law does ant apply a an r of
and Proreaions Code: The Camostat, Unna mvna
. q P
property wbobuildsor Intra es Nere.n.and whodoessuch work himself.,duouth his
Own employes. provided Nu such Improvements Are not Intended orortaed forsale. If,
hawever. Ne building or Imprasement Is sold within am year o(completlon, the owner.
builder will have da burden of paving that ke did not build or Improve fes purpose of
sale.).
❑ 1, es Owner of the progeny. am exclusively contracting wIN licensed cotnranata to
construct the project (Sec. 7044, Business and Professions Cade:) The Conoacart Li.
vena law does not apply be an ownes of property who builds or Improves thereon, and,
'
who contracts for such projects with a comosewKO licensed purauam in Be Conuactors
License Law.
❑ lamnemptimm,See. ,Bk PC(orthis Meson
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hemby.1 ires under penally of perjury aro of the following declar tmax
I have And will maintain eCenifirna of Camcnt 1. al6lnsu. for Worker'sCompea
sedan. As provided for by Section 3700 of the tabor Code, fm the performance of tbe
work for which this persalt is issued.
❑ 1 have and will maintain Worker's Compensation Insurance, As required by Section
,
37M of to Labor Cade, for the performance of did work for which this permit is issued.
My Workers Compensation Insurance varier and Policy number art:
Cartier. Mve2-67,G 2'We Policy No.: C7AfAe4633
CERTIFICATE OF EXEMPTION FROM WORKERS'
. COMPENSATION INSURANCE
(This section omit nut he completed If the permit is fa ane hundred dollar ($hast)
or less.)
1 unify Not in the perfornance of the work for which this permit Is iatucd, I shall ata
employ any poison many manner An M an become subjwi to the Workers' Compewllon
Laws of California. Dna
Applicant
NOTICE TO APPLICANT. If. after making this CeniOcam of Samurai... you should
become subject NO the Warms COmpewtan provisions of the LAW Code, you muss
faral comply with such provisions ar this permit shall be doomed mveked.
CONSTRUCTIONLENDING AGENCY
nn lending a$emy for the Performance of
1 bor thi that Nen h MnCLmn
which s ed (Sm.
Nc work for which this petrol' Is luood (Sm. 3097. Civ, Cd
Landers Name
lander. Address
i 1 certify that 1 have rod this pplication and Asa that the above Inrmmatlun is
' correct. I agree to comply with all city and county ordinances and beta laws relating In
building construction. and hereby suthotive repreantatim or this city to enter upon the
shove -mentioned property for Inspection purposes.
( (We) agree 1. cave, Indemnify and keep harmlea The City of Cupertino against
j liabilities, judgments, costs and expanses which may In any way neve Against sold City
In i APPLICeRNof the grantint of tANhis De
ANTUNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
'
Re -roofs
Type of Roof
Signature of AppllunUCont Data
HAZAR1515US MATERIALS DISCLOSURE
Will Na applicator or future building occupant n= or handle hrnrdous material
a dented by the Cupertino Municipal Code, Chapter 9.12, and the Health and Safely
Cod..Sma..25532(a)7///
All roofs shall be inspected prior to any roofing material being installed.
❑Yu gju
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or future building Occupant use equipment m devices which
It hazardous Air contaminants As defined by the Bay Area Air Quality Management
all new materials for inspection.
District?
❑ Yes
I have mal the har s materials requirements under Chapter 6.95 of the Califor.
Am Health A, SaAnyCade, Sections 255115.25533and 25531.1 understand And if the building
does rot currently hast a omni that It is my resp.mmlilly m a nilly the amateur of the
requirements which mum be met Prior to lauance Ora Ccroficae of Occupancy.
Signature Of Applicant Date
�,(/��—�1 2/•oew�
All roof coverings to be Class "Bt' or better
Owner or m smthmiz� Wk