12060096 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7672 SHADOW][ILL LN CONTRACTOR:THE I TOME PERMIT NO: 12060096
IMPROVEMENT SOURCE INC
OWNER'S NAME.: PLASTERER MICHAEL R ET AL 1400 COLEMAN AVE STE.1115 DATE ISSUED:06/15/2012
OWNER'S PIIONF.: 4089738422 SANTA CLA RA,CA 95050 PIIONE NO:(4081567-9710
❑ 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
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE AND REPLACE EXISTING WOOD SHAKE I
(commencing with Section 7000)of Division 3 of the Business&Professions LAYER
Code and that my license is in full force and effect. ROOF WITII A TIMBERLINE IID COMPOSITION ROOF,NEW
OSB DECKING,NEW TIGER PAW UNDERLAYMENT
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a cenilicate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance or the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code.for the performance of the work for which this
permit is issued. Sq.FI Floor Area:0 Valuation:$13000
APPLICANT CERTIFICATION
I certify that I have read(his application and slate that the above information is APN Number:36224021.00 Occupancy Type:
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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulatiats per the Cupertino Municipal Code.Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of RF.-ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed-If a roof is
h as owner of the property.or my employees with wages as their sole compensation, installed without f r a obtaining an inspection,I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penally of perjury one of the following three ALL ROOF COVERINGSTO BE CLASS"A"OR BE'ITER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE:
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ileallh&Safely Code.Sections 25505.25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for the perfomanee of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
Safely Code,Section 25532(x)should 1 store or handle hazardous material.
permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air
I certify that in the perfomtance of the work for which this permit is issued.I shall contaminants as defined by the Bay Area Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the
Compensation laws of Cali lhrnia. If,after making this certificate of exemption,I Ilcalth&Safety Code.Sections 25505.25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
Forthwith complywith such provisions or this permit shall be deemed revoked. Owner or authorized agent:
Dale:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGF.NCV
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 I hereby aEirm that there is a construction lending agency for the performance of work's
to budding construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Cir C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulatiats per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional