12030077 CiTY OF CUPERTINO BUILDING PERMIT
131JILDINGADIIRESS: 7740SQUIRCIIILLCT CONTRACTOR:KEVIN SULLIVAN PERMITNO: 12030077
ROOFING
OWNEWSNAME: LESLIEMARTIN 1696%'ALLFYOAES DR DA'Z'E ISSIJED:03/16/2012
OWNI?R'SPI101NE: 4082520407 GI LROV.CA 95020 1410NENO:(408)842-1057
❑ LICENSED CON`fRAC`fOR'S DECLARATION BUILDING PERMIT INFO: BLDG r.. ELECT r PLUAIB C
License Class Lie.k
N1ECH (- RESIDENTIAL r COMMERCIAL r
Contractor Dalc
hereby affirm that I am licensed under the provisions of Chapter 9 3013 DESCRIPTION:'1'17AR OI'F 17NISTINO ROOF. INSTALL 7/16
(commencing with Section 7111111)of Division 3 of the Dusiness& Professions
Code and[hill my license is in full force and effect.
L hereby affirm under penally of perjury one of the following hyo declarations:
I have and will maintain a certificate of consent to self insure lot Worker's
Compensation,as provided for by Section 3700 of the Labor Code,I'or[he
performance of[he work for which this permit is issued Sq.F[Floor Arca:0 Valuation:$12000
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for vhich this
permit is issued. AEN Number:36223029.00 Occupency'I)'pc
AI'1'L]CAN'I'CISR'1'11,'ICA9'ION
I certify that I have read this application mad state that the above information is
correct.I agree to comply with all ciiyand comuyordinances mid stale laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and herchy authorize representatives of this city to enter
upon lire above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep hamdessthe City ol'Cuperinoagainst liabilities,judgments, I8U DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
graining of this permit. Additionally,the applicant understands mid will comply
with all non-paint source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
Signature Date
RE-ROOFS:
❑ OWNER-111JILDER DECLARATION All roofs shall be inspected prior to amy roofing material beiig installed Ira roof is
installed without first obtainingan inspection,I agree to remove all new materials for
I hereby affirm that 1 am exempt from the Contractor's License Lay fur one of inspection.
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant: Dale:
will do the work,mid the structure is not intended or offered I'or sale(Sec.7044,
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO RE CLASS"A"OR BETFER
construct the project(Sec.7044,13usiness&Professions Code).
hereby affirm under penalty of perjury one of the following three IIA%ARDOUS MATP:RIALS DISCLOSURE
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self Insure for Worker's California Ilcalth&Safety Code,Sections 25505.25533,and 25534. 1 wiR maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance with the Cupertino Municipal Code Chapter 9.12 and the health&
performance of the work for which this permit is issued Safely Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided I'or by Additionally,should 1 use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Ray Area Air Quality Management District I will
maintain compliance with[he Cupertino Municipal Code,Chapter 9.12 and the
permit is issued I Icalth&Safety Codc,Sections 25505,25533,and 25534.
1 certify thin in the performance of dm work for vhich this permit is issued I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent:
Compensation laws of California. If,aller making this certificate ofexcmp[ion,I Date
become subject to the Worker's Compensation provision of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deci ed revoked CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of imrk's
APPLICANT CERTIFICATION for NN this permit is issued(Sec.3097,Civ C.)
I certify that 1 have read this application and state dial the above information is Lender's Name '
correct. I agree to comply with all city and county ordinances and state Imus relating
to building construction,and hereby authorize representatives of this city to enter Lender's Address
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, ,\RCII I"1'FCI"S DECLARATIONcosts,and expenses which may accrue against said Cit in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regula[ians per the Cupertino Municipal Code,Section
9.18. Licensed Profrssional
Sign:lure Date