BLD-2025-1942_SignedPermit.pdfCITY OF
BUILDING PERMIT
CITY HALL
10300 TORRE AVENUE • CUPERTINO, CA 95014-3255
PHONE 408-777-3228
CUPERTINO WWW.CUPERTINO.ORG
BUILDING ADDRESS:11902 SHASTA SPRING CT APN: 366 55 025
PERMIT NO: BLD-2025-1942
OWNER'S NAME: Jie Li
OWNER'S PHONE:
CONTRACTOR: TRI - CITY ROOFING INC
CONTRACTOR PHONE:
DATE ISSUED: Aug 12, 2025 ISSUED BY:ONLINE VALUATION: 19000
JOB DESCRIPTION: RE -ROOF; TEAR -OFF; ASPHALT SHINGLES (2000 SF); CLASS A ROOFING
LICENSED CONTRACTOR'S DECLARATION:
NO: 721697 EXP DATE: 04/30/2026
7000) of Division 3 of the Business & Professions
CONTRACTOR:
I hereby affirm
Code and
TRI - CITY ROOFING INC
that I am licensed under
that my license is in full force
under penalty of perjury
LICENSED CLASS: C39 LICENSED
ROOFING
the provisions of Chapter 9 (commencing with Section
and effect.
one of the following three declarations:
a certificate of consent to self -insure for Worker's Compensation,
performance of the work for which this permit is issued.
Worker's Compensation Insurance, as provided for by
work for which this permit is issued.
of the work for which this permit is issued, I shall
Worker's Compensation laws of California. If, after making
provisions of the Labor Code, I must forthwith comply
as provided for by Section 3700 of the
I hereby affirm
❑ I have and will maintain
Labor Code, for the
Section 3700 of the Labor Code, for the
not employ any person in any manner so as to
this certificate of exemption, I become subject to
with such provisions or this permit shall be
✓ I have and will maintain
performance of the
❑ I certify that in the performance
become subject to the
the Worker's Compensation
deemed revoked.
HAZARDOUS MATERIALS DISCLOSURE
requirements under Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I
read the hazardous materials
compliance with the
V I have
will maintain
handle
Air Quality
Sections
Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(a) should I store or
air contaminants as defined by the Bay Area
Chapter 9.12 and the Health & Safety Code,
hazardous material. Additionally, should I use equipment or devices which emit hazardous
Management District I will maintain compliance with the Cupertino Municipal Code,
25505, 25533, and 25534.
EPA LEAD -SAFE DISCLOSURE
will be responsible for this project.
Firm Certification No:
Lead -Safe Certified Renovator
Firm Name:
❑ An EPA
Certified
V No EPA
Lead -Safe Certified Firm is required for this project.
CONSTRUCTION LENDING AGENCY
that there is a construction lending agency for the performance
of the work which this permit is issued
I hereby affirm under penalty of perjury
(Section AV7, Civil Code).
Yes ✓❑ No
Lender's Name:
Lender's Address:
APPLICATION CERTIFICATION
and state that the above information is correct. I agree to comply
hereby authorize representatives of this city to enter upon
and keep harmless the City of Cupertino against liabilities,
of the granting of this permit. Additionally, the applicant
Code, Section 9.18.
with all city and county ordinances and state
the above mentioned property for inspection
judgements, costs, and expenses which may
understands and will comply with all non -point
2025
I certify that
laws relating
purposes.
accrue against
source regulations
Signature
I have read this application
to building construction, and
(We) agree to save indemnify
said City in consequence
per the Cupertino Municipal
Date Aug 12,
EVERY PERMIT ISSUED SHALL BECOME INVALID UNLESS THE WORK ON THE SITE AUTHORIZED BY SUCH PERMIT IS COMMENCED WITHIN 365 DAYS AFTER ITS ISSUANCE,
OR IF THE WORK AUTHORIZED ON THE SITE BY SUCH PERMIT IS SUSPENDED OR ABANDONED FOR A PERIOD OF 365 DAYS AFTER THE TIME THE WORK IS COMMENCED.