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CITY OF CUPERTINO 77777777;
BUILDING DIVISION PERMIT INFA
(?FVITI0N�
BUILDINJG,fij.)D,(tESN STELLING RD LANDMARK DEVELOPMENT PERMITNO.
OWNER'S NSA/ME: PERMIT ISSUE DATE
. AS PALMAS STELLING LLC 1307 S MARY AVE STE 120 09/03/2008
PHONE: SANrfARY NO. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING NEW TWO STORY TOWNHOUSE BLDG LEPERMIT LUMB MECH
lcd21399 SP
ro 0 a 0
o p LICENSED CONTRACTOR'S DECLARATION
m I hereby affirm that I am licensed under provisions of Chapter 9(commencing Job Description
I U with Section 7000)of Di i'on 3 of the Business and Professions Code and my license is
a° in full force and cffecL 3 3 Y�
Z License Class Lic.#
M Date '7 Contractor_ P_J ( lln .
CPS DECLARATIONQk —
fC a I understand my plans shall be used as public records
J94U 4!/b
4 O y Licensed Professional
rn OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractors License Law for the
Oyfollowing reason.(Section 7031.5,Business and Professions Code:Any city or county
{i which requires a permit to canstmct.alter,improve,demolish,nr repair any structure
prior to its issuance,also requires the applicant for such permit to file a signed statement
z c that he is licensed pursuant to the provisions of the Contractor's License Law(Chapter 9 Sq.Ft. Floor Area Valuation
%h (commencing with Section 7000)of Division 3 of the Business and Professions Code)or
y that he is exempt therefrom and the basis for the alleged exemption.Any violad'on of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not more than five hundred dollars($500). P Y YP
❑1,as owner of the property,or my employers with wages az their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044,Business Required Inspections
and Professions Code:The Contractore
ts s License Law donot apply to an owner of q p
property who builds or improves thereon,and who does such work himself or through his
own employees,provided that such improvements are not intended or offered for sale.If,
however,the building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑1,as owner or the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business and Professions Code:)The Contractor's Li-
cense Law dors not apply to an owner of property who builds or improves thereon,and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑1 am exempt under Sec ,B&P C for this reason
Owner Dale
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
❑I hsve and will maintain a Certificate of Consent to self-insure for Worker's Compen-
sation,az provided for by Section 3700 of the Labor Code,for the performance of the
work for which this permit is issued.
❑I have and will maintain Workees Compensation Insurance,az required by Section
3700 of the Labor Code,for the performance of the work for which this permit is issued. '
My Worker's Compensation Insurance carrier and Polity number are: .
Carrier. ' i)l)I) e Poli No.: Q
CERTIFICATE PEXEMPTION .FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed lithe permit is for one hundred dollars($100?
or less.)
I certify that in the performance of the work for which this permit is issued,I shall not _
employ anyperson in any manner so as to become subject to the Workers'Compensadon
Caws of California.Date
Applicant
NOTICE TO APPLICANT:If,aMr making this Certificate of Exemption,you should
become subject to the Worker's Compensation provisions of the Labor Code,you must
Z forthwith comply with such provisions or this permit shall be deemed revoked.
z0
`-' CONSTRUCTION LENDING AGENCY
(-+rte-+ I hereby affirm that there is a construction lending agency for the performance of
IY, > the work for which this permit is issued(Sec.3097,Civ.C.)
W
Lender's Name
z Lenders Address
U Q 1 certify that 1 have read this application and state that the above information is
V.— correct.I agree to comply with all city and county ordinances and state laws relating to
® �4building construction,and hereby authorize representatives of this city to enter upon the
Uabove-mentioned property for inspection purposes.
(We)agree to save,indemniry and keep harmless the C'�of Cupertino against
r�r liabilities,judgments,costs and expertsaes wA;minw acerae against said City
U`,� in consequ f the g ' g o(th' pcPPL N NOS ND�WWITH ALL NON-POINT Issued by: Date
Re-roofs
Sign§t orApplican antrac o Date
HAZARDMS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building occupant store or handle hazardous material
az defined by the Cupertino Munici i Code.Chapter 9.12,and the Health and Safety
Code,Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
❑Yes u
If a roof is installed without first obtainingan inspection,I agree to remove
Will the applicant foto bolding occupant use equipment ordevices;which P
emit hazardous air contaminants defined by the Bay Area Air Quality Management all new materials for inspection.
District?
El Yes No
1 have read the hamrilous materials requirements under Chapter 6 95 of the Califor-
niaHealth&Safety Code,Sections 25505, 533 and 25 4.1 un thaiifthcbuilding
does not cu�hico
t it' my re I' o' heoccupant of the
squirem miss r Bea rGYctr�paney. 0 Signature of Applicant Date
C All roof coverings be Class" `
--• a��n Y Date' oto g 'or better
)41
� --� CITY OF CUPERTINO
NEW SINGLE/MULTI FAMILY DWELLING
CUPERTINO PERMIT APPLICATION FORM
APN# Date:
07- (_) '7-_)_7, 2,q F �2- 1
Building Address: `-` 4Lw
` 082-9 -W, S->-Mkt12,
Mailing Address (if different from building address):
Owner's ]dame: Phone# :
_
Cont actor: ,� Phone#: L,a` j --7-_3 3
Q_
Fax 4: i� `7-3S— 5�"Z%i
Contractor License #: Z-/ c y
Cupertino Business License
Contact: / Phone#: 4f `7�
k� Fax #: Ll u _7_3S5-- 92-
Alternate
r2Alternate Contact: Phone #: 44 r` -7
T. AG c.-w-, k—> Fax #:
Single-Story ❑ Two-Story Three-Story ❑ Basement [:1 Hillside E]
Multi-family Apartment ❑ Condo. ❑ Townhouse
Sq.Ft. Living Area(Including Basement &Attached Garage: Sq. Ft. Garage ( etached Only):
Fc-p (,P- 1' 1 a, 3�� 5 �tF-T-
Valuation:
33.E BCeU
Job Description: ��J�i,�,� � � �. �-i—�� N 7��.�;✓� � �. '��
Type of Construction (Usage Class): Occupancy Type:
1 FR, 11FR ❑ 11, 111, V-lHR ❑ 11, 111, 1V V-N P3
Project Size: Standard Large Major❑
Green Building: Must attach completed Green Building Checklist to the plans
Green Building Points Achieved:
For help, contact Build it Green at www.builditareen.ora