040901254
4
CITY OF CUPERTINO
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CONT UCTO"NFOAMATiO1�I
BUILDING DIVISION PERNHT
aaulZDING ADDRESS:
PALISADE BUILDERS INC
PERMITND.04090125
19503 STEVEN
OWNER'S NAME:
PERMITLSSUBDATB
CUPERTINO HOUSING PARTNERS
LLD909 ALMA STREET
04/20/9009
E:
SANITARY NO, CONTROL NO.
(650)470-4700
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDGO ELECTO PLUMB MECH
LS I�
LICENSED CONTRACTOR'S DECLARATION
Job Description
1 hereby aRrm WILL I am licensed Under ProvisionsOT Chapter 9 (anmmeneing
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with Section 7") of Division 3 of the BualnmA and ProuLdons Code, AM DIY license is
in foil ramnnd ercmt. 8�
NEW CONDO -1130 SQ. FT.
LIceea Cce' Lk.P 5 •6
Date s Contractor PAL, NYr� f.,•Aew,
AR T9 DECLARATION
HDEC
I underwnd my plans shall W used as public recut&
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that I Am exempt fmm the Contracmes License law for the
following reason. (Section 71313, Busies And Prefesdom Cade: My city or county
which requires a permit m croshoom alley, Improw, demolish. Or repair any structure
prior to its issuance. also mquires the Applicant for such remelt W rile a signed su eau nl
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provision of the Contractor's Licence Law (Chapter 9
(commencing with Section 7000) of Division 3 of the Business and Probation. Code) or
$130808
that he is exempt themfmm and the butt for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 70713 by any Applicant for a permit subjects the applicant to a civil penally of
not marc Nan five hundmd dollars (5500).
0 1, As Owner of the property, os my employees with wages u their Aute compenssdon,
RequiredIns ections
w0ldothe AM& toad the Amebae lsnot Intended oroffered for Asks (Sm.70",Business
sed Pmfeedam Cade: The Comewt hes License Law dean Mt apply An an Owner of
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propeny who holds on improves Ihermn. sed who does such work himself m through his
awn employees. provided that such Improvements ere act Me osaffemdfmsaln IL
however, We Wilding or improwmeat Is mid within arc year of mmPledm. the owner -
Wilder will love the burden of proving that k did rot heid or improve for purpose of
sale.).
0 1, a Owner of the property, am emluevely contracting with licensed contrmton te
construct the project (Sec. 7044, Business and Pmfmdans Cade:) The Convector's U•
cense law does not apply at an Owner of property who Wilds or improv t amon, and
who mnvaets for such projects with a commetor(A) licensed pursuant to the ConeatoM1
License Law.
l Am exempt under Soe , B k P C for this mason
Owner Data
WORKER'S COMPENSATION DECLARATION
1 hereby Iffirm under peoely of perjury Can, of the following dxlan0ona:
I have and will maintain. Certificate of Consent to self -insure fn Wo ker'ACompen-
wion, as provided for by Section 3700 of We Labor Cede, for the performance of We
"A for which this permit is ismad.
0 I have And will maintain Worker's Compensation Insurance, As required by Section
3700 of We labor Cede, for Ne performance of the work for which Nin permit Is issued.
My Worker's Compensation Insurance Carrier and Policy numberme:
Cartier. Mn,Trs'�n TsirCPoliryHo.:l�?ooer�.74'9
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
(Thissection need cwt bemmpleted If the permit Is foramhundred dollen (SIM)
or kat.)
I certify that in We perform.. of to ..,it for which this pamdt is issued, l Nell am
employ any person in any manner an As to become subject to the Workers! Compensation
Laws of Celifomie. Data
Applicant
NOTICE TO APPLICANT: IC after meting this Certificate of Exemption, you should
became subjext in We Worker's Compensation provision of 0w Labor Code. you must
foMwiih comply with such provisiom or this permit abet W demand revoked.
CONSTRUCTION LENDING AGENCY
1 hereby All that then i.a conarnu n IcAWmj.gency far the periermanttof
the work for which this permit is issued (Sec. 3097. Civ. C.)
,
Lender's Name
Lender's Addma
I cxrdfy that 1 have mad this application and sate that tite above information is
'
corm. 1 agree to comply with all city and county ordinances and sus lows relating to
building consvuctlon, and hereby Authorise mpm enativ of this city to enter open the
shove -mentioned pmpeny for Inspection purposes.
(We) agree to ave, indemnify and keep hamleas the City of Cupertino against
liabilities, Judgments, costs and expenses which may in my my accuse against sed City
In consequence of the granting of this Permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
Type of Roof
^? 'e
Signatu. Appli mtsmlar DM
HAZARDOUS MATERIALS DISCLOSURE
Will ted applicant or future Wilding accupa more ser haMlc handout material
As defined by the Cupertino Municipal Code. Chapter 9.12. and ted Health and Semy
Ca. Section 25532(4)1
All roofs shall be inspected prior to any roofing material being installed.
❑ res
If a roof is installed without first obtaining an inspection, I agree to remove
Witt the applicant Or sewn siding «aapant use equipment or devices which
emit havardous airmntsmiamis u depend by the Bay Area Air Quality Management
all new materials for inspection.
District?
0YaCo
I have mad the handras materials requirements underChapter 695 ofthe Califor.
'
nla Health&Safety Code, Sectimts 25505.25533 tied 25534.1 w*a that irdre Wilding
does not...ity hew • tenant. that it u my m mous hiRty m notify the occupant of rite
WAwhich mut be met prior to Women of a Cenlficam of Occupancy.
Signature of Applicant Date
.2/m
All roof coverings to be Class "B" or better
Owner m amhodud agent