0409017102
C
�v
Cis �
aG
72
UC
0E
O
U2
CITY OF CUPEWfINO
`nom tet,7
BUILDING DIVISION PERMIT
ON"Cl2A.C'OI2`�pNFUMA.' ON's
Ex.t�YF
BUIIDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO 04090171
OWNER'S NAME:
HOUSING PARTNERS
11119109 ATMA RRRT-
PERMITISSUEDATE
no Zoo /2
E:CUPERTINO
SANITARY 10 OL NO.
ARCHITECTIENGINEER:
BUIIDINO PERMIT INFO
BLDG ELECT PLUMB MECH
O l�
LICENSED CONTRACTOR'S DECLARATION
Job Description
P
I Mreby affirm that 1 am incomes under provkion, of Chapter 9 (commencing
With Section 90110) of DIVlalOn 3 of the BuWem end Profession Coda, and my license is
mroti
Licensere ma site°• Lk. Qf,.qe46
m CI s M
NEW CONDO -1102 SQ. FT.
Dam — Comncmr PAL.
ARCHITECTS DECLARATION
I understand my It shall be wed a puhlic rccnr_ds `
Licensed Paskashma
0 NER-BUILDER DECLARATION
I hereby afnrm that I am exempt from dm Contractors License Law for the
following moron. (Secllon 7031.1. BOal.as end Professions Code: Any city or county
which requires a Permit to construct, alter, imp raw, demolish, or toped any structure
prior N its issuance, elm requires the applicant far such permit to File a signed statement
Contractor', ISansc LAW (Chapter 9
Sq. Ft. Floor Area
Valuation
that be is licensed punuant to the pmvislom ofthe
(commencing with Section 7000) of DiNskn 3 of the Business and Professions Cork) or
that he Is exempt Nctefrmm and the basis for the alleged exemption. My violation of
APN Number
Occupancy Type
Secllon 7031.5 by any Applluar four a permit mbjecu the applicant to a civil penalty of
not more than five hundred dollars (M),
the properly,, emPla)eca wdthwagesutlmk rote cmmpenudess
❑l
84.00 Required Inspections
is extdo Text N. Business
the work.CurekOut
will dOthwmk,mds:
rt's LiMed urem LAW den .t apply lf An Ownsr
and Professions; Cork: The Contncmh License apply M
The
q P
his
n suchmoode himself Or through is
properly who builds improves; Ncreon, and wed on,
Am SAI
own employees, provided Nn aah improvements art not IeteMed eo0ered for ole If,
i
wners
the Wilding care year ofImproefor Ne Owner-
Wilder w10 haw Na Wrrkn of Proving Nat ha did not build or Improve for Purpose of
Wilderher rdmprowmentBtoldwdid
Wilder
rete.!.
❑ 1, An owner a one properly am exclusively contracting with licensed..hetes te
construct he project (Sec. 70th, Business and prnfeWons Corl The Contractor' Lb
conse Law does not pply an an owner Of propany who Wilds or Improves Nemon. and,
who contracts for such projects with a eontnctods) licensed pursuant in the Committee,
License Law.
❑ l am exempt under Sea . B alt P C for this rcsson
Owner Date
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury aro of the following d.lasAllanl:
,.and will maintain ACenificamo of Coneal LO W INnsua fa Workers COmpem
inion, o provided for by Section 3700 of the Libor Code. for the performance of the
work for which this permit k las.d.
1 haw and will maintain Workers Compensation Insurance, u required by Section
3700 of the Labor Cork, for dm performance of the work for which this Permlt k Issued.
0"
My Workmen Compensation Insurance carder and Polity number Art:
Cartier. AAAZI -9"v 7t_ ?y C Paltry NO.: �etdbn+2S33
CERTIFICATE OF EXEMPTION FROM WORKERS'
,
COMPENSATION INSURANCE
rlbk sectimt odd not be completed Ifthe Permit Is form. hundred dohs HHOO)
ter leas.)
1 codify that in An performance of the work for which this Permit is laved, I Nall not
employ any Penoa In any mm.r An a or become subject in Ne Workers' CamPennthen
Law, of California. Date
Applicant
NOTICE TO APPLICANT: If, after making thin Certificate of Exemption, you should
become subject 10 the Worker's Compensation previsions of 1W labor Cork, you must
forthwith comply with such provisions Or this permil shall ism deemed rewired.
CONSTRUCTION LENDING AGENCY
I hereby alarm that there its construction lending agency forthe Performance of
the work for which this permit Is Issued (Sec. 3197, Civ. C.)
Lender's Name
Lender'sAddre,a
I anifY that I ban mad this application and sum that the Above Information is
correct. l spa to comply with all city and county Ordinances and sure laws totaling to
building convection, and hereby institution represenutiws of this city to enter upon Nc
show -mentioned property for Inspection purposes.
(We) mime to ave, Indemnify And kap hsrmkss Ne City Of COPmdflO Against
j liabilities. Judgments, cats and expense, which may In any way acerae against mid City
In consequence of the granting Of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by:9 Date
SOURCE REGULATIONS.
Re -roots
Type Roof
Signature Of Applinn✓Cmarama Dak
HAZARDOUS WATERIALS DISCLOSURE
of
Will the applicant or future Wilding ma upam store or handle hi udous miterial
A, dented by the Cupenlno MunklPal Code. Chapter 9.12, and the Health and Safety
.Litudc. sec, xssua>7
All roofs shall be inspected prior to any roofing material being installed.
❑Yomu
_building
If a roof is installed without firs[ obtaining an inspection, I agree to remove
Will the aPPlinm(Orrffuture Occupant use equipment or device, which
haardoua an contaminants As denned by the Bey Area Air Quality Management
all new materials for inspection.
let? 1'
❑Yea inn
I have mad the hansrdims materials requirements underChapter6.95 Of dm Catiforr.
nla Health Se Safety Cadc,Secdon,25503,x3533 and45534. I understand theUfthe building
docs not curtcotly haw A tenant, that It Is my responsibility in notify the occupant of the
requirements which must W met poor Or issuance of a Certificate or Occupuncy'
Signature Of Applicant Date
mea
All roof coverings to be Class "B" or better
Owner or swisscm Date