04090105a BFB'zF�EBE
��IdE
Ay=�
LG
oil
3
5a�
�y_. �SEEZF�
S$
02
z
F�
a�
Uz
UC
0E
�4
U2
CITY OFCUPERTINO
v>r>rtti;1';a;�"."
�*CO FRA,CTOR
BUILDING DIVISION PERMIT
TNFORtMAT1®N::.
aha ay w%z?.
BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMUNIb4090105
19505 STEVENS CRK If A
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTINERS
909 AL
NE:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG EO PLUMB MECH
O
LICENSED CONTRACTOR'S DECLARATION
Job Description
o
licensed uer provisions; of Chaper 9 (commencing
by arm Nat 1 am nd
1 herffi
P
with Section 7") of Division Sof the Busineaad Pmfeamen Code. and my license Is
infullfereadeffecl. B Lieg
License
NEW RETAIL BLDG. A (2576 SQ.FT.)
Deo: '1/-,7 iti— contractor •. IIA/ ci/hr
ARCHnECI`S DECLARATION
'
1 undcnund my plena dull ha uhl c recoNs
ylio
Licensed Professional
DECLARATION
Oat
from Ne Canlnnoh License Lew for the
snnm that 1 from
1 hereby I am exempt
1. , Business
following moan. (Stiction 7 alter. and
tow wan Cade: My do orrcountyum,
improve, de
which requires • permit to pima Impmw, demolish, or airsig any umment
UmA3thconstruct.
e a
prioruslctuanoo,alsorequires theapplicant forsuchthe Law(natement
Sq. Ft. Floor Area
Valuation
Ca acar'sefilese
pSemantm the of the Canlrcbr'a License Law (Chapter
(that commencing of Division of Basi^..s and
(commencing mitt Section of DiWasof
vi Code) or
$241552
and r al on. M
Nu he V exempt therefrom and the, bash for Ue alleged excerption. MY viNWon of
APN Number
Occupancy Type
Section 7031.5 by my applicam for r permit subjects the applicant in a civil penalty of
oro mon Nan Rw hundred dollars ($50)}
[11, an owner of the Property, ormy employcn with wages u Nab sole compennall.
Required Inspections
q P
Will do the woes, and thouratme is not intended mortared Imsale(Sec. 7018, Bwircu
and Professions Code: The Canuactora License Law dos, not appy to an owner or
who builds or improves Narcan, and who dors ouch work himsel f or through his
propony
own employees. provided tha such Improvements me not Intended mortared forWe. 14
however, the Wilding er Improvement is sold within one yearof compimia, the owner-
Wilder will have the burden of proving WI he did nm Wild or Improve for purpose of
❑ I. As owner of Ile Properly rte exclusivelymai comrnrng with limned mnuacun
rod Code:) The Contractors i.
construct de project (Sec. 7044.nwner
_
and
of nice Wildaorow roves Norton.ad
Law canowapplyjcm ny who
L[�/
I
wore
itherofproperty
where for such pojeav wiNaconuactor(a)li¢vedpurauanitoNe Conuctota
La..
t.1 .1."-•,x.1,
❑Iron exempt undo See .B&PC for this tenon
0 1aa exempt
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under Penalty of perjury one of the following declarations:
I haw and will mainuin aCenifieam of Consent to ulf-inaM for Workees Compen-
a0an, u provided for by Section 3700 of Ne Labor Code, for the performance of the
work for which this permit is issued.
0 1 Nor aml will maintain Workmen Compensation Inwrame, as required by Section
3700 of Ne labor Cade, for de pcAermaco of Ne wort for which this permit u IaneJ.
My Workers Carepenndon Its. carrier and Policy number rte:
Gn1er. AR.ur,%L TLC Policy No.:=20000.2Q30
CERTIFICATE OF EXEMPTION FROM WORKERS
'
COMPENSATION INSURANCE
(This section need trot be completed If the permit is foronc hundreddollan (1110)
or less.)
I cenify that In the performance of the work for which this Permit is Issued, I shall net
employ any person in my mums as he becorna subject to the WorkerCompensation
LA. of Cdifomie. fate
Applicant
NOTICE TO APPLICANT: IC after making this CeniOcate of Exemption, you should
become subject to the Worker's Compensation provision of the LeWr Code, you am
forthwith comply with such provision or this permit Mill h doomed mvoked.
CONSTRUCTION LENDING AGENCY
I hereby grim this there is a construction lending agency rot IM performaoo of
the work for which this permit Is banned (Sm. 3097, Civ. C.)
Lenders Name
Lenders Address
1 cattily that I have rad this application and cote that the aWw information 0
correct. I agree u comply with all city and many ordinamn and aa¢ laws relating to
building construction, and hemby authenve representatives, of this city to must upon Ne-
above-mentioned property for inspection puryoae
(We-) ,,me to ave, indemnify and keep hsrmlaa the City of Cupertino agent
j Imbilitim,juegmenB. come; IterateAnd expenses which may In ay WAY Iterateagahw said City
in <.nw,.tcc of the gnmag of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NOWPOINT
Issued by: Date
sOURCFy REGUU�j(1 `^-2 /^
�:.1J���c / o�
Re -roofs
Signature of A¢a or Dau,
HAZARDOARDOUS MATERIALS DISCLOSURE
Type of Roof
Will dim applicant building oocupautortor battle
Hedth anmrterid
noMuni
an defined by the Cupertino Municipal Cade-. Chapter 9.I2. and the Ncalth and Safety
cndc, semtien zss3z(a37
Yea
❑1Mo
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use mqulpmem or dcvlms which
mit hamdous all contaminants as deOncd by the Bay Amo Air Quality Management
all new materials for inspection,
DBuia7 /
❑Yca QNo�
Ihave rad thehvaAmumawna4mquimmenB a oder Chaper6.95 of he Califon
nu Health& Salety0ode,Scctian 25505.25533 w325534. 1 undcrswb Nrtifde Wilding
does not currently have a unat. this It u my raponibillty o notify tie mcuPat of Ne
mquimmmn which my be met Pnor raaam a fa c'fm"oramPrnay.
—
Signature of Applicant Date
� — 4 2 f `�S'
All roof coverings to be Class "B" or better
-�Zfif4
Owner or mthori of d agent Dow