04090216U
CITY OF CUPERTINO
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO. 04090216
OWNER'S NAME:
CUPERTING HOUSING PARTNERS
11D9139 AT ATREET
FERMITISSUEDATE
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SANITARY O OL NO.
ARCHiTECDENOINEER:
BUILDING PERMIT INFO
BLDG ELP.Cf PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
lois Description
I herby affirm Thal 1 am licensed under Provision. of Chapter 9 (commencing
with Samoa 70fk)) of Dividers Sof the Boal,. and foie& alnus Code. and my Ilcmue b
I fun sere Ano erect. g8�6k�
License class Lrc.11
NEW CONDO -, 1368 SQ. FT.
Dee Comm P r519D•G�
ARCHITECTS DECLARATION
,
l undenuml my plms ahallh'-
Limmed Pmfessiom
OWNER-BUI DECLARATION
I hamhy affirm that I am ex pi fru. tie Contractor, License Law for the
following moon. (Swoon 70313. Business and Profession. Code: Any city or county
which mqulrc. a Permit to emmum, cher, Improve, demolish, or Mpalr my munurc
prior to itsissuance, alm "Uses the applicant forsuch mornittu file a.ignmi slarement
Sq. Ft. Floor Area
Valuation
that ha is licensed purn"m to the provisions of Be Contractor's License Law (Chapter 9
(commencing with Section70B0) of Divl.ion 3 of the Business and Pmfeulnns Code) nr
that ha I. exempt ihemfrom and the bub for de allcgcd cmmptim. Any Acdetlon of
APN Number
Occupancy Type
Section 7031.5 by anyepplicanlfor a permit Objects the applicant to&civil penallyuf
not more gun five hundmd dollen ($NIB).
❑ 1, u owner of tie property, or my employees with wages u tielr Ole compenullon,
31620084.00 Re uired Ins ections
will do the work, and theauucture is not intended or offend for sale (Sm. 7041, Business
and Poefeaalona Code: The Cmu mmr'. License Law deal not apply to an owmr of
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property who builds m Improves Mornon, and who dos mch work himself or through his
'
own employees, provided Ihauueh Improvements arc not Intended or offered forum. If.
however, me building or Improvement b mid within ort year orcompletion, the owner.
builder will have the burden of proving Nu he did not build or Improve for purpose of
lam,).
❑ 1, as owner of the propeny, am exclusively contracting with ficemed contractors to
eonstrocl the pmjeci (Sec. 70th, Business and professions Code:) The Comractor's Lt.
won Law deal not apply to an owner of prolan who build. or improves fere., and
who c.lracts for such project, with a contractor(s) licensed Perauanl to Ne ConuatoM1
License Law.
❑ 1 em exempt under Sec. . B k P C for this rcsaon
Owner Dau
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Faulty of perjury one of the following dwlaratious:
1 ham and will malnuin a Cenlfiwte ofCousenl to mRlnmrc fe, Worker-Compen-
.it.., u pro ridad for by Section 3700 of de LAW, Code, for tha perfomuna of the
work for which Nb Nonit is Issued.
❑ 1 haw and will maintain Workefa Compensation Insurance, u sequined by Section
3700 of the Labor Code, for Ne pertormance of tie wick for which this Pctmit is Issued.
My Woheeg Compensation lnmrsnw cooler and Policy number tee:
Cartier. Mat.1'e.9yiC .Tb Policy Ne.:C &N—h 2J�J�'30
CERTIFICATE OF EKEMP ION FROM WORKERS'
COMPENSATION INSURANCE
This Motion oed not becompleed filhe Icnnit b (mom hundmddollma ($100)
or less.)
1 wnify that In the pcifnmm. of the wart for which this Permit b Inod, I .hall not
-
employ anyperson In any manner an u to become subject the Workca'' Compensation
laws of California. Data
Applicant
NOTICE TO APPLICANT: IL after making this Cenificarc of Exemption, you should
Wronm subject m the Worker's Compensation pmvmors of the labor Code, you mull
fonhwilh comply with such provision. or NL permll shall he deemed revoked.
CONSTRUCTION LENDINOAOENCY
thi eat then h construction lending agency for the penfmmence of
1 hor
Which s 30
the work for which this permit Is Issued (Sec. 7M7, Civ. CJ
Nano
Lender'. Address
1 wooly that 1 have read this application and sue that above Information Is
1 agree to comply with all city and county ordinances and slam laws relating to
building construction, and hereby suborn representatives of this city to enter upon the
shove -mentioned properly for inspection purpose.
(We) Agree to save, indemnify and keep harries the City of Cupertino &&Aim[
liabilities judgments, costs and expenses which may In any way accrueagainst Said City
In consequence of tie graining of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS
A'
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Re -roofs
Type of Roof
Signature of Applies r Data
HAZARDOUS MATERIALS DISCLOSURE
Will rte applicant or fulum building eccup.m store or handle hssamus Marcos]
a dafined by the Cupertino Municipal Code. Chapter 9.11, and the Health and Safety
Code. Section 15532UT?
All roofs shall be inspected prior to any roofing material being installed.
❑ Yet
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant m fulum building occupant DO equipment or devices which
I herardous air.marammts u defined by the Bay Arta Air Quality Management
all new materials for inspection.
District?
❑Yes Nu
I have mad the hasam.smucdab requirements undm Chaper6.95of do Califor-
niaHulthB Safety Coda, SeNma25505.25533 md25571.1 UncmW that If the building
dew set minemly hem A emms this 11 b my rcspmsibililY to m KY tie occtspant of the
mquimmemu whi run mel poor. iuusnce of A CertiIICAM of OCcuPaneY.'gnature
of Applicant Date
'o,rc
All roof coverings to be Class "B" or better
owner er.mnervad I