09060142CITY OF CUPERTINO
BUILDING DIVISION PERMIT
+dIRAQ2�}�«4TI�r�
BUILDING ADDRESS:
PERMIT NO.
7587 SQUIREWOOD WAY
WESTSH()RE ROOFING INC
09060142
OWNER'S NAME:
PERMTT ISSUE DATE
S A CONTROL NO.
(408)694-0060
ARCHITEC (ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
I hereby affirm that I am licensed under provisions of Chapter (commencing
with Section 7000) of Division 3 of the Business and Professions Code, and my license is
-1
in full fore and cff3�� Z 1
RE—R001 INSTALL FELT & LANDMARK 30 COMP CLASS A
License Class — Lic. M
23
Date Contractor 1Q Sf r�i D (�
ARCHITECTS DECLARATION
SQUARE; i
I understand my plans shall be used as public records
Licensed Professional
OWNER -BUILDER DECLARATION
I hereby affirm that 1 am exempt from the Contractor's License Law for the
following reason. (Section 7031.5, Business and Professions Code: Any city or county
which requires a permit to construct. alter, improve, demolish, or repair any structure
prior to its issuance, also requires the applicant for such permit to rile a signed statement
Contractor's license Law (Chapter 9
Sq. Ft. Floor Area
Valuation
that he is licensed pursuant to the provisions of the
(commencing with Section 7000) of Division 3 of the Business and Professions Cade) or
8 3 O 0
that he is exempt therefrom and the basis for the alleged exemption. Any violation of
APN Number
Occupancy Type
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of
not more than rive hundred dollars (5500).
36227006 .00
❑ I, as owner of the property, or my employees with wages as their sole compensation,
Required Inspections
will do the work, and the structure is not intended or offered for sale (See. 7044, Business
and Professions Code: The Contractors License Law does not apply to an owner of
property who builds or improves thereon, and who does such work himself or through his
own employees, provided that such improvements are not intended or offered for sale. If,
however, the building or improvement is sold within one year of completion, the owner -
builder will have the burden of proving that he did not build or improve for purpose of
sale.).
❑ 1, as owner of the property. am exclusively contracting with licensed contractors to
construct the project (Sec. 7044• Business and Professions Cade:) The Contractor's Li-
cense Caw does not apply to an owner of property who builds or improves thereon, and.
who contracts for such projects with a contractor(s) licensed pursuant to the Contractor's
License Law.
❑ I am exempt under Sec. B & P C for this mason
OwnerDate
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's Compen-
..ation, as provided for by Section 3700 of the Labor Code, for the performance of the
work for which this permit is issued.
have and will maintain Workers Compensation Insurance, as required by Section
700 dMe Labor Code, for the performance of the work for which this permit is issued.
My Worker's Compensation htsutance carrier and Policy number are:
Carrier. 15 f_fA tC Fut. ✓\ A Policy No.:. .1-1— Z — Zf3 O
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dollars ($100)
or less.)
I certify that in the performance of the work for which this permit is issued, I shall not
employ any person in any manner so as to become subject to the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If. after making this Certificate of Exemption, you should
become subject to the Workees Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for the performance of
the work for which this permit is issued (Sec. 3097, Civ. C.)
Lender's Name
Lender's Address
I certify that I have mad 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 of this city to enter upon the
above-mentioned property for inspection purposes.
(We) agree to save, indemnify and keep harmless the City of Cupertino against
liabilities, judgments, toss and expenses which may in any way accrue against said City
in consequence of the granting of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON -POINT
Issued by Date
4 /2. K�'
Re -roofs
Type of Roof
Si inure of ApplianUettactor Date
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building occupant store or handle hazardous material
as defined by the Cupertino Municipal Code. Chapter 9.12, and the Health and Safety
Calc,Section 25532(a)?
All roofs ihall be inspected prior to any roofing material being installed.
❑ Yes p'IOo
If a roof i installed without first obtaining an inspection, I agree to remove
Will the applicant or future building occupant use equipment or devices which
it hazardous air contaminants as defined by the Bay Area Air Quality Management
all new materials for inspection.
strict?
❑ Yes /ONo
I have mad the hazardous materials requirements under Chapter 6.95 of the Califor-
nia Health & Safcty Codc, Sections 25505.25533 and 25534.1 understand that if the building
does not currently have a tenant, that it is my responsibility to notify the occupant of the�/-