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CITY OFCUPERTINOPE
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BUILDING DIVISION RT
BUILDINOADDRESS:
PALISADE BUILDERS INC
PERm"'NG'04090132
19503 STEVENS CRK 4 13S
OWNER'S NAME:
ST PersnBT BDATE
CUPERTINO HOUSING PARTNERS
909 ALMA STREET
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SANITARY NO. CONTROL NO.
(650)470-4700
ARCH TTECT9ENOINEER:
BUILDING PERMIT INFO
BLDG EO LECT PLUMBMECH
O
LICENSED CONTRACTOR'S DECLARATION
lob Description
I Money affirm that 1 am licenced under provisions of Chapter 9 (commencing
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with Seedier 70D) of Division 3.f the Business ad Professlou Cada, ad my license is
infunse n, ll fonceand effect
3 046
NEW CONDO - 1106 SQ. FT.
LiceLle. g
Dam Contractor {H U S H 0 a a 0,..�
—
.,
ARCHITECT'S DECLARATION
I Woers}�nd my Plain aM1JI M 11, d u sell acorda
Licensed professional
lER-BUILDER DECLARATION
I hereby Affirm that 1 am exempt from the Contractors License Law for the
following mason. (Section 7031.5. Business and Professions Cale: Any city or county
which mquims a Permit to conurucL alter. Improve, demolish, or repair any Structure
prior to its issuance. also requires the applicant for Such permit to Ole a signed statement
that M is licensed pursuant to the provisions of the Contractor's License Law (Chapter 9
Sq. Ft. Floor Area
Valuation
(commencing with Section TWO) of Division 3 of the Business and Professions Code) or
12 8 O 3 0
Nal he is exempt therefrom and the but, for the alleged eumptlon. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects Ne applicant In a civil penalty of
not more Oen five hundred dollar (5300}
❑ 1, u ownu of Ne property, or my employees with wage u Neo sole eompemation,
Re uired Ins ections
wilide the wok, and theauucWse is nut intended -offend (cousin (Sm. 7044, Busineas
and Profadom Code: The Contractors License Law does not apply m an owner of
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propenywho Wilds or]mproves thereon. and wMdoessuchwmkM1im¢IfuNmugh his
own employes. provided that such improvements are trot intended Walruses forsale It.
however, Ne Wilding or Improvement is sold within Arc year of compledon, the owner -
Wilder wig have the burden of perving that M did not build W Improve for purpose of
ask.).
0 1. a owner of the property, am exclusively oonuaming with licensed contruron m
construct the project (Sec. 7614. Business and Professions Code:) The CWtrsemri Li -
came Law dos not apply to an owner of property who Wilds or improves &men, and,
who contracts for such projects with a contractors) 0cemad pursuant to the Cnnm tmb
License Law.
❑ 1 am exempt under Sec. . B R P C for this mum
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
1 have and will maintain a Certificates of Cement On self -insure for Wod sCompen.
satlon, as provided for by Section 3700 of the labor Code, for the performance of Ne
wok for which this permit is issued.
❑ 1 have and will maintain Workers Compensation Iwrance. as required by Section
3700 of the LaborCode, for the performanceof the work for which this pemtit t, sound.
My Workers Compemnlon losunnee carter and Policy number art:
Cartier. Fl/1.TeS%tG TSJC PolicyNu.4i000�.113c514S
CERTIFICATE OF EXEMPTION FROM WORKERS'
'
COMPENSATION INSURANCE
This secdoo need not becompleted IfIM permit h forone hundred triton (f lou)
or IcssJ
I cen]fy that In the performance of the wok for which this permit is ]wood, I Shell not
employ any person in any manner an at to became subject to tM Workers'Compema0on
Laws of California. Dam
Applicant
NOTICE TO APPLICANT, If, after making this Cardinale of Exemption, you Should
become subject to the Workers Compcmation provisions of the Labor Code, you most
forthwith comply with such provisions or Nis permit Nall M seemed .1 std.
CONSTRUCTION LENDING AGENCY
1 hereby afOrm thou Vert is a construction ending agency for the Performance of
the wok for which mu permit Is issued (Sec. 31197. Civ. C.) -
Lenders Name
Landers Addles
1 certify that 1 have read this application and Som that the above information is
'
cora. I gree ro comply with it city and county oMnanceund mu laws mlning In
Wilding construction, and Mmby authorize mpresenouive of this city to coon upon the
above-mentlund property for impaction purposes.
(Wer) agree to an, Indcmufy and keep harmless; the City of Cupertino against
liabilities,judgments, costs and expense which may In any way same against mid City
In consequence of the treating of this permit,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS. /y -1/
-AS
Re -roofs
Type of Roof
Signuurc of Appljp VCoDam
HAZARDOUS MATERIALSDISCLOSUREOSURE
WIII the or future building aecupant Brom or Nnsk hsaoonad ety
Safety
by isle o Manidryl Col. Oupler 9.12. and Use HeJN and Safety
u de , Cupert
CodeSestina 256321.)7
See 1321")
All roofs shall be inspected prior to any roofing material being installed.
"y yino
If a roof is installed without first obtaining an inspection, I agree to remove
WIII the applicant or f����\m building oceupant use cyuipmenl or device which
It haurdnus air commonam s u defined by Ne Bay Area Air Quality Management
all new materials for inspection.
Diuricl7
❑ You 1/7HIa-
I have mai the hamo n, mamrialarequirements under Chapter6.95 midst Califor-
niaHeal" SafciyCodc.Sado¢25505,25533 and 255341 undemmund Nn Ifthp building
dos not currently have a unant, Out it 4 my responsibility to nudity the acupant of the
requirements which mug be met prior miuuence of a Certificate of occupancy.
Signature of Applicant Date
H -.2h err
All roof coverings to be Class "B" or better
Owner onmh ad agcm % Dau