04090120B mpZO
x
zb�
3
0 U
�00
t- LZ
fin
1 1
1
1 E
W
Ucr,
CITY OF CUPERTINO
BUILDING DIVISION PERMIT
C4�V4.""'M R`�INFORMATIYON
..�'�R";ax''sd
BulLDINGADDRESS:
PALISADE BUILDERS INC
111111 N'04090120
1503 STPVP.NLq CRK If 110
OWNER'S NAME:
PERMIT ISSUE DATE
CUPERTINO HOUSING PARTNERS
909 ALMA qTRPRT
n4/2n/9.nnc;
E:
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITCCDENGINBER:
BUILDING PERMIT INFO
BO EO PLO MECH
O
LICENSED CONTRACT'OR'S DECLARATION
Job Description
1 hereby affirm that i am licensed under provisions or Chapter 9 (commencing
with Section 7010) of Division 3 o dm Business and Profession, Code, arW my license is
nan
dcttueLueneCla6
NEW CONDO -1487 SQ. FT.
ueg
Data �-a t+ s Cr
ARCHIIECI•SDECLARATION
1 unMrsund m plw shall W u I rtwrN
Licensed Profes,onal
OWNER -B ILDER DECLARATION
I hereby a(mm that i am exempt from the Contractors License law for the
following reason. (Sudan 7031.5. Business and Profession Code: Any city ar county
which rtyulrts a permit W cantrucl, alter, narrow. demoull, or mpolr any mroctum
prior In its luuance, also acquires the applicant for such Ismail to file a signed sou rem
Sq. Ft. Floor Area
Valuation
the m is licensed punuanuo the provision of the Cannot License Law (Chapter9
(commencing with Section 7000) of Division 3 of the Business and Profwions Cade) or
17 •� 13 5
thin he k exempt themfrom and the basis for the alleged escmptlon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant far a permWubjecu the applicant o a civil penalty of
not mart tun live hundred dollars (5500)
❑ 1. as owner of the property. or my empioycm with wages as them sole compensivan,
31620084 00Required actions
e
will do the work. and umawcmmisan, intended oroffered far sale (See.7044,Business
and Profess am Code: The Co use art License Law deal not apply W an owner of
9 P
property who WIIN or improves therace. and who does such work himself or through hts
awn employee, provided Nn such improvements am not intended aroQertd 1. ale. It,
however, the Wilding or improvement is cold within ane year of completion, the awms-
Wllder will have the WWan of proving Out he did not Mid or Improve for purpose of
ask.).
❑ 1. as comer of lax property am exclusively contracting with licarm d eontneton ro
construct the project (Sec. 71114. Ballroom and Profession Cade:) The Conuanner'a Li-
cence taw does not apply W an owner of property who Wilds or impows thereon, ted ,
who contracts for such projects with a eontractm(s) licensed purwm W the Contractors
License law.
❑ lameaemptunder See ,BAPCfmatsreum
Owner Dau
WORKER'S COMPENSATION DECLARATION
1 hereby aMan under penalty of perjury one of Ou fallowing dectantlau:
Nm and will maintain a CeNOm a of Content W Ulf -insure far WerkeraCompn-
u Ion, u provided for by Section 3700 of the labor Code, for the Performance of the
wmkfor which ibis permit is issued.
on Insurance, yuimd by Section
❑ 1 have and will maintain Workers Compensation re
1700 of the labor Cade. for the performance cram work for which this permit is Issued.
My Workers Compenatian Inu•wn�nce carrier and Policy number am:
Carder. Ith4S` y!kV _ 7" Porky No:62 AfS301—
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(This medoe heed trot haeoaplcmd if tlx permit Is fmone hundred dollars (SIM)
or less)
1 octal, shot in ac prfotnance of the work for which this Permit is issued. I sba11 net
employ any Kron In try manneran as W became subject to the Workcn' Compewtion
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. after making this Cenirmam of Exemption, you should
become subject to the Worker's Compinse tion previsions of the Labor Code. you mum
foMwia comply with such provision or this Permit mhall ha deemed mwked.
CONSTRUCTION LENDING AGENCY
I totally affirm that them Is construction lending agency for the perfurmanu of
the walk for which this permit Is issued (Su. 3097, Civ, C.)
Lenders Name
lenders Acidness
I certify that I have read this application and sum that the show information is
'
cozen 1 agra W comply with all city and county ordinances and sum law relating W
Wilding construction, and hamby sotharin rtprtxnutiw of this city in enter ups the
above-mentimed property fp inspection pnrmd•
(We) agree W save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, cos, and expenses which may in any way aura against laid City
In consequence of the Sranting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. _
4
ZZ
Re -roofs
Type of Roof
Signature of ApplicanUUQQ n amr —fir Dam
HAZARDOUS MATERIALS DISCLOSURE
Will 00 applicant or futum building occupammae or handle hvardous material
v deRned by the Cupertino Municipal Code. Chapter 9.17, and he Health and Safety
ode. Section 2553x(.)7
Cl Yet No
All roofs shall be inspected prior to any roofing material being installed.
If a roof is installed without first obtaining an inspection, l agree to remove
Will Lha applicant or forum building Occupant use eyuipmcnt or devices which
I hit tardnu, air comaminanas u defined by he Bay Arts itQuality Management
all new materials for inspection.
imaict7
❑Yes patvu
I haw read the hvardrear renals mituirtmcnu under Chapurli.95 ofthe Calier.
nets HulthhSafoyCode.Smnma255U5,25533"25534.1unhrsu "Iftie Wilding
does mat currently how a mart, that it i, my nspoauibility W madly the oocuPanl of the
mquirtments wnleh mum W met prior W iwance of a OmOrNamar Occupanq.
Signature of Applicant Date
,
All roof coverings to be Class "B" or better
Owner or utharind agent Dale