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CITY OF CUPERTINO`•
BUILDING DIVISION PERMIT
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BUILOING ADDRESS:
PALISADE BUILDERS INC
PEKMITNO.O4O9O178
OWNER'SNAM :
CUPERTINO HOUSING PARTNERS
ALMA STREET
PERMIT ISSUE DATE
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SANITARY 0 OL NO.
ARCHITECTIENOINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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LICENSED CONTRACTOR'S DECLARATION
Job Description
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by o 1 Am licensed under provisions of Chapter 9 (commencing
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with Setian70tgH of Dividon 3 of de Buainesa and Profeuiaa Gnda, and my license is
in full force end effect. n
Liccnmr LIC# 644546
NEW CONO-1104 SQ FT
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ARCHITECTS DECLARATION
Iundcuund ry pl ata NMI_ rttnr s
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Licensed Profs
OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from she Cmeonscrors License Law for the
following Mason. (Section 7031.5. Business and Profeuim , Code: Any city or county
which requires a permit to Conmuct. alter. Improve, demolish, Our mpair any structure
pricer an its Issuance. Alan RQuime the applicant forsuch North to file a 6sincd statement
Sq. Ft. Floor Area
Valuation
that he (.licensed furmanl to the pewlsioasof the Camncmr's Uanm Law (Chapter 9
(commenclmg with Section 700gnf Division 3 of the Bminua and Pm(malons Code) w
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant hot a permit subjects the applicant to. civil penalty of
not more Nan five hundred dollars 135001,
0 1. Ad ownc, of the property, ar my employees w1h.1. As their ma coepermaden,
31620084.00 Required Inspections
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will do the work,and Nemescum is not Intended or offered for sale (Sec. 7041, Busimv
and Prefessiona Code: The CanlranoLlceme Law does not apply a an owner of
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property who builds orimproaes dtemon, and whodoeaauch .,it intrinsic, throngh his
own employees. provided Ns such impmmmenu AM not Intended aeRered forasla If.
however, the building or Improvement is sold within oro you of completion. she owner
builder will have the burden of proving that he did not Wild Or improve fee purpose of
ass.).
0 1, a owner of the property, am exclusively contracting with Immund coronations an
construct the project (Sec. 7044, Business are Professions Code:) The Contractor's LL
cense Law deal not apply N an owner of property who Wilds or improves demon, and,
who contract, for such projects with. co stnsemr(A) licensed pursuant to Can Ce0naaera
License Law.
O l Am exempt under Sec. , B h P C fa this mason
DaeWORKER'S
COMPENSATION DECLARATION
ir
I hereby affum under penalty of perjury ane ofthe following double m:ave
and will melmain a Cenlftcaa of Consent to self -Insure fm Workers Compose,
u provided for by Sedan 3700 of she Labor Code. for the performance of the
work for which this penmil is iuund.
0 1 have and will maintain Worker's Compensation Imunsnce, u required by Section
-
370t1 of she tabor Cade. fa No performance of the work for which Nis permit Is Issued.
My Workers Compensation Imnunnce carrier and Policy number am:
Cartier'. 1149-!%1 24, CPolicy No.:C2QOM2513
CERTIFICATE OF EKEMP ION FROM WORKERS'
'
COMPENSATION INSURANCE
Rha mclim need not N complesed if tha permit Is rare= hundred dollars (110tH
.tics$.)
I certify that In the performance of the work for which this permit Is Imued, I shall not
employ any person in any mannoran As to hemsm subject to the Workers' Compemati.n
Laws of C.Ilfmnla. Data
Applicant
NOTICE TO APPLICANT. It, after making this Cenl0cate of Exemption, you alo uW
become subject to the Worker's Compensation provisions of the Labor Cade, you mus
forthwith comply with such provisions Or this perm0 shall he domed revoked.
CONSTRUCTION LENDING AOENCY
1 hereby Affirm that them Is connmctinn landing agency for the performance of
the work for which this permit is Issued (Se. 3097, Co. C.)
Laser's Name
Iander's Address
I certify that I have and this application and me that the show Information I.
coned I Ince to comply with all city and county ordinances and Marc laws [Clain{ e
building construction. and hereby authorixe,epmamaives of this city to Omer upon lin
aleve.mentioned property for Inspection purposes
1 (We).gee wave, indemnify Nd keep harmless the City of Cupertino against
j IIab1111iesjudgmenu, calm and expenses which may In any way am= Saint sold City
in
I APPLICANT UNDERSTANDSf AIND WILL Co_WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIONS.
Re -roofs
41 li'
sigmuare of AppIMMVC..mCw DAM
HAZARD0kr§ MATERIALS DISCLOSURE
Type of Roof
Will Neapplicant or future building oreup un none a handle haeudous maarisl
As defined by de Cupertino Municipal Code, Chapter 9.12. and the Health and Safely
Cone, Section 25532(a)7
All roofs shall be inspected prior to any roofing material being installed.
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If a roof is installed without first obtaining an inspection, I agree to remove
WHI the applicant or future building Muslim use equipment or devices which
It haxatEous air contaminants As defined by the Day Arca Air Quality Management
all new materials for inspection.
uinT
❑ Yes 0:04-
1 have mW the haciumus materials requirements underChapm 6.95 of Ne Glifa-
ria HulN&S.fnyCode, Section 25501.25533 And 25334.1 undersand one ifde building
dWar Can cunealy have a smart. Ns it is my reapoalbllhy Io notify the occupml of dace
reytommena which must be over prior Or issuance of a CeniOcae of Occupancy.
Signature of Applicant Date
4r'21d
All roof coverings to be Class "B" or better
Owner or a horimd qan Date
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