05070087CITY OF CUPERTINO'�a,�'
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BUILDING DIVISION PERMIT
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BUILDING ADDRESS:
PALISADE BUILDERS INC
PERMIT NO.05070087
19501 STEVENS
OWNER'S NAME:
PERMIT ISSUE DATE
MENLO EQUITIES''
909 ALMA STREET
08Z09/2005
IlWE: `
SANITARY NO. CONTROL NO.
(650)470-4700
ARCHITECTIENGINEER:
BUILDING PERMIT INFO
BLDGO ELECT PLO
UMB MESCH
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• LICENSED CONTRACTOR'S QECLARATION
Job D0SCi1pt100
1 hereby aGirm Nal 1 am licensed under pmyhomm of Chapter 9 (commencing
with Section 700(f) of Division 3 of she Business and Professions Code, and my license is
I.faurmaandaffect.
DEFERRED TRUSS CALLS
Us.nse cl"� - 'c hamar
PD FOR ON ORIG PERMIT 04090240 NO NEW PERMIT
AR I7ECrSDECLAR ION
IN HOUSE ONLY
I under and my plans shall be used as publidrecmJa
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby sflmn Nat I am exempt from M4 Co-imarm's License Law for the
fallowing mason. (Semon 7(171.5, Business and Pialesslans Code: Any city or county
per
nal requires a ped,m cnewc4 altar, improve,' dcmoluh. or ¢pair any almcture
prior m its issuance. Also raqulrer Ne applicant for m6h Permit to file aligned statement
NUM is licensed the the Contracu's Lt.. law(Clupmr 9
Sq. Ft. Floor Area Valuation
putsusntm proHaioe of
(commencing with Section 7000) of Division 3 of Ne Business and Professions Code) or
$ O
Nat W u exempt Merrimac and the basis for the Alleged evmp jon. Any violation of
Y
APN Number Occupancy Type
Semon 7031,5 by any applicant far • permit subjeCu the applicant to a civil penalty of
not more than five hundred dollars (5500).
0 1. u owmr of the pmpmy, m my employees with cage u Neto wlccampensNm,
31626884.68Required
will do the warp and the structure is not Intended araffered for sale (Sm. 70U, Business
Inspections
and Profeuiae Code: The Complicates Ljamae LAW. decd trot apply m An owner of
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property who builds orimpreaves themo ,and whodacuuch work Mmselfar Maugh his
own employee, prtwided thatwch Improvements are not intended or offered for We. If.
however. Ne Wilding or improvement is veld within ane year of compmlim. the owner.
Wilder will haw: the When of proving that be did not build or improve for purpose of
talc.).
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❑ 1, As owner of the property. am exclusively contracting with licensed contractors to
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construct the pmjea (Sec. 7014, Business and profusions Cade:) The Contracm/d U.
orae Law doe oat appy he an owlet of property, mho Wilds or improves thereon, and
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who contracts for such projects with a eontraemr(s) licensed pursuant to the Commerce,
License Law.
❑ I am exempt under Sec. .B A PC for this mown
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Owmr •' Dam
WORKERS COMPENSATION DECLARATION
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I hereby aiBrn under penalty of perjury castor Ne following dabn0om:
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of Coent m ¢eum If-1far W.,W.Comper-
q m I have and will mainuin a Certificate; ns
.fon. u provided far by Sector 3700 of the LAW, Code. fm the perfarmance of Ne
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work for which this permit is issued.
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❑ 1 have and will maintain Workces Compensation Insurance, as required by Section
3700 of the Labor Code, fm Ne performance of the work for which this permit is issued.
My /7Workce.(,,�Compensation Imnm
ua carrier and Policy number am: �y�
Carrie. A GQ67a C, Pollq N.r`F06 a�wq)+ 3
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CERTIFICATE OF EKEM PI70N FROM WORKERS'
COMPENSATION INSURANCE
(This section need not W completed if the Permit H for am hundred dollars l5100)
or IM)
I anify that In the peffonnanca of the work for which this Permit is issued. I shall not
employ any pecan in any moneran u to become subjecno the worluen' Compensation
Law. of California. Dam
Applicant
NOTICE TO APPLICANT: IL after making this Ceninom of Exemption. you should
become subject in Ne Warkees Compensation provisions or ora LAW Cade, you most
forthwith comply with such provisions; or this permit shall be sentenced revoked. .
CONSTRUCTION LENDINO AGENCY
1 hereby affirm that there is a construction lidding agency for Ne performance of
Me work fat which this Permit 4 issecd (Sec. 3097, Civ. C.)
L.mmed Name
,
Lcndce. Address
I comfy NU 1 have mad this application and smut that the shove Information is
cortex 1 agree to comply with all City and county oNlonm<s and sum laws mating in
Wilding construction, and hereby auNonse representatives of this city to enter upon the
drove -mentioned property for inspection perpetuates.
(We) agree no ata, indemnify and kap harmless the City of Cupertino against
liabiti0ea, judgments. cru and expense which may in any way acme against said City
in
APPLICANTuenceUNDERSTA of the g aS Als permit. WILL COMPLY WITH ALL NON -POINT
Issued by: Date
SOURCE REGULATIO
Re -roofs
Type of Roof
Sig nstore o Appli onuacrar Dam
HAZARDOUS MATERIALS DISCLOSURE
Will Ne applicant or forme Wilding occupant am or hander hvUdous material
As, defined by the Cupertino Memel I Code. Chjpenr 9.12, and the Health and Safety
Code. Semon 25532(.)7
All roofs shall be inspected prior to any roofing material being installed.[3y.,
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If a roof is installed without first obtaining an inspection, I agree to remove
W0II the applicant uveas WiW I oc ccupsnt uequipment or dcviaa which
Il hv]Nne air.."anants U To,by the Bay Area Air Quality Management
all new materials for inspection.
Daniel?. ,.
❑ Ycd
Ihawmedtheh® sm ,.,mmquimmenuunder Chapmr6.95o(theCalifor-
ni,H.I ASdmy Cedc,Semmu25505.25533a Z53d.Iondorrtsndthatifde Wilding
Jam not currently hew a wnnu Net it is my ri p iNlity m notify de oaupant of thc
af. certificate ore Fancy.
m�quyimv�menu which mu erpnern, iasganaa
Signature of Applicant Date
�"- a -`Dam
All roof coverings to be Class "B" or better
owner
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