12030099 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10672 DIiEP CLIFF DR CON'IRACI'OR:ITTERSEN-DEAN INC PERMIT NCI: 12030099
OWN'ER'S NAMIS: LANGLAIS'I'I-IFRESE li AND DAVID D 7980 ENTERPRISE DR DATE, ISSUED:03/192012
OWNER'S PHONE: 4083076482 NEWARK,CA 94560 1'IIONE NO:(510)494-9982
❑ LICENSED CONq'RACTOR'S DECLARATION C I ' r'
BUILDING PERMIT INFO: BLDG ELECr I.—I
License Class Lic.H F [' r'
MF,CII RESIDENTIAL COMMERCIALContractor Date
1 hereby uffnrm that I.am licensed ander the provisions of Chapter 9 ,1013 DESCRIP'r10N: REMOVE EXISTING COMP AND INSTALL NEW
(commencing with Section 7000)of Division 3 of the Business& Professions COMPOSITION
Code unit that my license is in fall force and effect. 37 SQUARES
1 hereby affirm trader penalty of perjury one of the following two declarations:
I have and will maintainu certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which thispenntt is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the perfomrance ofthe work for which this Sy.Ft Floor Area:0 Valuation:$14025
permit Is Issued.
A I'I'LIC,\N'I'CIiR'1'IFIG\'PION AM Number:35604012.00 OccupancyTypc
I certify that I have rend this application and state that the above tnforn(dion is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,an(]hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilitics,judgnlentt,
costs,anti expenses%%]rich rally accrue against said City in COIISC(laence Of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
grunting of this permit. Additionally,the applicant understands and will comply )
with all non-point source regulations per the Cupertino Municipal Code,Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Issue(] by: Date:
Signature Dine
❑ OWNER-BUILDER DECLARATION
Rh:ROOFS:
hereby affirm(hill I tall cvempt from the Contractor's License Lanfor one of All roofs shall be inspected prior to any roofing materia]being installed If a roof is
the following inn reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,Or my employees with wages as theirsole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature ol'Applic nt: Date:
I,as owner of the property,ani exclusively contracting with licensed conGeGmrs to
construct the project(Sec.7044,13usiness&Professions Code). ALI,ROOF COVERINGS TO 131:CLASS"A"OR.BEATER
1 hereby affirm under penally of perjury one of the following three
Ideclarations:hvenwiIL\%ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Workers
Compensation,as provided Ibr by Section 3700 mf the Labor Code,for the I have read the hazardous materials requirements under Chapter 695 of the
performance of the work for which this permit is issued. California Ilealth&Safety Code,Sectihns 25505,25533,and 25534. I will nn aintain
I have and will maintain Worker's Compensation Insurance,as provided Ibr by compliance is ilh the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)should I store or handle hazardous material.
Additionally,should I use equipment or devices %[rich emit hazardous air
permit is issued contaminants as defined by the Ray Area Air Quality Management District I will
I certify haat in the performance of t e work forwlich this permit is issued,I shall maintain compliance"'till the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any numner so as to become subject to the Worker's Maids&Safety Code,Sections 25505,25533,and 25534.
Compensation law:s of Cnlio)rni;l. If alter narking this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,I must O%''rner Or nnthnrized agent:
forthwith comply with such provisions or this permit shall be deemed revoked Date:
AITLIG\N'I'CEIi'1'IFICA'1'ION CON'STRUGFION LI.NDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is construction lending agency for the performance of work's
correct.I agree to comply with all city cad county ordinances and state laws relating 'for which this permit is issued(Sec.3097,Civ C.)
to building construction,laid hereby authorize representatives of this city to enter Lender's None
upon the above mentioned property for inspection purposes.(We)agree to save
indenmity and keep harmless lie City o'Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting ofthis permit.Additionally,the applicant understands and will comply
with all 31011-point Source rcgultials per tire ane Cupertino Municipal Code,Secti .\RCHITECI"S DECLARATION
9.18. I undersnad my plans shall be used i s public records.
Signature Date Licensed Professional