12060132 CITY OF CUPERTINO BUILDING PERMIT
BUILBING ADDRESS: 10229GLENCOE DR CONTRACTOR:WESTERN ROOFING PERh11TNO: 12060132
SYSTEMS
OWNER'S NAME.: DUYGU DEMIRLIOGLU 1328 WHITE OAKS RD DATE ISSUED:06/21/2012
OWNER'S PHONE: 4083661993 CAMPBELL,CA 95008 PIIONF.NO:(931)278-1837
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
MECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
I hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION:I EAROFF WOOD SI IAKE ROOFING AND REPLACE WITII
(commencing with Section 7000)of Division 3 of the Business&Professions STEEL
Code and that my license is in full force and effect. SHAKE PER ER 3098
1 hereby affirm under penally of perjury one of the following two declarations:
1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for(he
performance of the work for which this permit is issued.
1 have and rill maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0 Valuation;$14500
permit is issued,
APPLICANT CERTIFICATION - APN Number:32630018.00 Occupancy Type:
I certify 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 of this city to enter
upon the above mentioned properly for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep hamiless the City of Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Dale Issued by: Date:
❑
OWNER-BUILDER DECLARATION
RE:ROOFS:
hereby affirm that 1 am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.I fa roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all ne%v materials for
1,as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Dale:
I,as owner of the properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business&Professions Code).
ALI-ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE:
Compensation,as provided fix by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Ileallh&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cuperlino Municipal Code.Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which(his Safety Code,Section 25532(1)should 1 stare or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Qualify Management District I will
I certify that in the performance of die work for which this permit is issued,I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Workers Health&Safely Code.Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Workcr's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith conipl) with such provisions or this permit shall be deemed revoked. Dale:
APPLICANT CERTIFICATION CONSTRI[MON LENDING AGENCY
I cenify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agencyfor the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authority representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCIIITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18- 1 understand my plans shall be used as public records.
Signature Date Licensed Professional