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CITY OF CUPERTINO'
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ANNrlYA�Y
BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMITNO. 04090164
OWNER'S NAME:
ICTIPERTIND HOUSING PARTNERS
Q09 ALMA .—STREET
PERMR 1SU0 DATA
E:
SANITARY N C OL N0.
ARCHITECTIENOINEER: -
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I hereby Man that I am limned under Provisions of Chapter 9 (crmmmcln{
with Section 7ak0 of Division 3 of she Business and Profession, Coda. and my licom is
tnrull forte end effect. ��i>'6
Llcenxe ClW Lk.g
NEW CONDO -1478 SQ. FT.
Date Con ASda� Or/On•s
DECL
ARCHITECTS DECLARATION
'
tun mandmy plan' still] leered esnW`e rtenrds
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby Affirm that I am exempt from the Conlncim'a License Lew for the
following reason. (Section 7031.5, Business and Profesalnm Code: Any city or county
which requires a permit ro customer, Alar. Improve, dematiAh, or repair any structure
prior it, its Issuance, also requires the applicant for such permit to file asigned Statement
Umnse Law 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant o the provision of the Contractor's (Chapter
(commencing with Section 70110) of Division 3 or be Broin u.suid Profc l na Cade) ur
that he Is exempt demefrom and AS, basis (o the alleged exemption. Any violaYon of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not mart than Bw hundred dollar, (5500).
0 1. AS owner of site property, or my employes with wages AS their sole cemp=nsation,
31620084. 00 Required Inspections
will do the work and that structure is not hooded or offered to, Sale (Sec. 7044. Business
and Professions Code: The Comm crow Limns, Law deal rot apply u an owner of
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property who builds or Improves thereon, and who dauuch work bimxelf or through his
own employees. provided that such improvements Are not Intended oroRered for Aute. IL
however, the building or Improvement it Sold within one year of completion, the owner.
builder will have the burden of proving that he did nm build or Improve for purpose of
seta.).
0 1. as mores of W property, am exclusively contracting wide licensed contractors to
construct the pmject (Sec. 7044. Business and Professions Code:) The Contractor's LI -
cents law docs not Apply to rot owner of property, who builds o Improve Merton. and,
who contracts for such prejecu with a eontoclmr(O licensed pursuant to dee Contat
License Law,
I em exempt under See . B k P C for this tenon
Own r Date
WORKER'S COMPENSATION DECLARATION
1 hereby af0rm under penally of perjury am of the following dealarelknoV
hem end will malmsin a CeARcta of Consent to selr-Insure for Wartime, Compen-
, n,a provided fm by Section 3700 of the Labor Code, fm Ne performance of the
sstion
work for which NB permit Is issued.
❑ 1 have and will maintain Workers Compensation Insurance, At required by Section
31M of Na laho Code, few the performance of the work fm which this permit h island.
My Workee, Compensation Insurance envier and Policy number am:
Carrier: MdJe'S%i[ 79.0 Policy No,:C2LkCp�S.s'3 S
CERTIFICATEOF EXEMMON FROM WORKERS'
COMPENSATION INSURANCE
(ThisSonim toed not W completed hole,wall Is formate hundrtddollan (SIgB
Us ksa)
1 certify that in the performance of the work for which Nis permit IS Issued, I shall no
employ any Nixon in any manAcrdel AS Ir hmmme Nbjecl to the Woloura' Creo peNetion
Laws of California. Data
Applicant
NOTICE TO APPLICANT: If. afar making this CWVICALe of Exemption, you should
become subject in the Worker'A Compensation provisions of the Labor Code, you mns1
' forthwith comply with such provisions or this permit shell is deemed revoked,
i
CONSTRUCTION LENDING AGENCY
1 hereby Affirmat them is i, a construction lendingRemy for the performance of
' the work for which lista permit h issued (Sec. 3097.7.Civ. C.)
Under'. Name
'
Lendeta Address
I eenlfy that 1 have mad this application and mm that site &bow Information h
' correct. I agree to comply with all city and county oNlnatee,and shite hes mislin{ a
building co stramon, ad hereby Authorizer representatives of this city to enter upon she
shove -mentioned property for inspection purposes.
(We) Agree to SSW, indemnify and keep hatmless the City of Cupertino against
j Ilabllitiea.judgments. coin and expenses which may In any way Acne against Wit City
In APPLICeRNof the Starting of IANhisD
ANTUNDERSTANDS WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATION
Re -roofs
Type of Roof
/l"f”. %S 4/-2/-
Signature of ApplicaroCcantracclor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant w future Wilding occupant start or handle hazardous material
AS defined by the Cupertino Municipal Code, Chapter 9.12. and the Health and Safety
Com. Sees. 255324)?
All roofs shall be inspected prior to any roofing material being installed.
DYet
If a roof is Installed without first obtaining an inspection, I agree to remove
Will the applicant or foute building occupant use equipment or devices which
hexardam air coouminans as dmtined by the Bay Arca Air Quality Management
all new materials for inspection.
strict?
OYU, p}tlo
I have mad Ne hoardrias materials requirements under Chapter 6.95 or tW Cables.
.Is Health B Safety Cas, Sections 25505,25533 And 25534.1 under" that tribe Wilding
docs not currently haw A writ, that It Is my responsibility to notify the mcupanl ar Out
requirements which must he met rim or Issuanceof a couthate ter oc�cepancy.
Signature of Applicant Date
roof coverings to be Class "B" or better
Dwyer sur amAorrm g=m DataAll
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