12050148 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7565 ORANGE BLOSSOM DR CONTRACTOR:SI(WA'I'URI:BUILDERS PERNII'II NO: 12050148
INC
OWNER'S N'A)IF.i PEfRANOVIC DUSAN AND MIRIANA 1141 OLD COUNI'R)'RD S'IT D DATE ISSITW 05/212012
OWNER'S PHONE: 4083433886 BELMONT,CA 94002 PI I0SES(1:(8001644-74111
❑ LICENSED CONTRACTOR'S DECLARATION r r r
BUILDING PF,RNIII' INFO: BLDG ELECT' PLUMB
License Class Lic.q r r r
\IECIi - RESIDENTIALr-
Date
1 hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: illi-R001 REMOVE'.SI IAI(P.ROOF INSTALL 7/16"OSIS
(commencing with Section 7000)of Division 3 of the Business&Professions MINIMUM 151.11 IT.I.I,PRESIDEN'fMI.CWMI',
Code and that my license is in full force and effect.
herehv affirm under penalty of perjury one of The following two declarations:
I have and will maintain a cerin ica(e 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 this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Arca: Valuation:S10500
Section 3700 of(he.Labor Code, for the performance of the work for which this
permit is issued.
APN'Number:3661I055.00 Occupancy'I'ype:
API'I,ICAN'1'CER'1'IFICA'I'ION
I cerlify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives uflhis city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We.)agree to save
indemnify and keep harmless tile City ofCupertinoagainst liabilities,judgments. WIT14INr 180 DAYS OF PERMIT ISSUANCE OR
casts,and expenses which may accrue against said City in consequence ofthe 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally.the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OW'N'ER-RUILDER DECLARATION RF:ROOFS:
All rook shall be inspected prior to any roofing material being installed, If it roof'is
1 hereby affirm that I am exempt from the Contractor's License Law for(Inc of in sin led willimit first obtaining an inspection. I agree to renmve all new innicriad. for
the following two reasons: inspection.
I.as owner of life property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044. Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business&Professions Code). ALL ROOF CO\'F:RIN'GS'I'O BE CLASS'b�"Olt IIF:I"fFK
I hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS NIA I ERIAI S DISCLOSURE
I hint and will maintain a Certilicme of Consent to self-insure I'or Worker's I hasr read the hazardous materials requirements under Chaqner 6.75 of the
Compensation,as provided fur by Section 3700 of the Labor Code,for the California llcalth&Safety Cade,Sections 25505,25533,and 25534, 1 will maintain
performance of the work for which this permit is issued. compliance wi01 the Cupertino Municipal Code,Chapter 9.12 and the Math&
I have and will maintain Worker's Compensation Insurance,as provided fir by Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Section 3700 of the labor Code for the performance of the work for which this Additionally.should I use equipment or devices which emit hazardous air
contaminants as defined by the(fav Area Air Uualitr Management District 1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the perlirmance of floc work for which this permit is issued.I shall health&Safety Code.Seclions 25505,25533,and 25534.
nn(employ amI person in any manner so as to become subject to the Worker's
Compensation laws of California, If.after making this certificate of exemption.I Owner or anihorizrd agent:
become subject in the Worker's Compensation provisions of the Labor Code.I must D ltc:
forthwith comply with such provisions or this permit shall be deemed revoked.
CON'S'I RUC'I[ON LENDING AG ENC('
APPLICANT'CERTIFICATION I hereby alfrm that there is if construction lending agency lir the performance of work',
I certify that I have read this application and stale that the above information is for which this permit is issued(Sec.3097.Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We.)agree to save Lender's Address
indemnify and keep harmless the Cit'of Cupertino against liabilities.judgments.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit,Additionally,the applicant understands and will comply :(RCIIffF.(:'I'S DF:(:L.-Ut,VI'ION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9,18.
Licensed Professional
Signature Date.