12070158 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20171 JOHN DR CONI'RACFOR:LINDY ROOFING PERMIT NO: 12070158
COMPANY
OWNER'S NAME: FURUSHO WALTER K TRUSTEE 476%Y TAYLOR SI' DATE ISSUED:07/192012
OWNER'S PHONP:: 4082531189 SANJOSE,CA 95110 PRONE NO:(408)286-9990
❑ LICENSED CO\fRA(7FOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG [ ELECT I- PLUNIB r
License Class Lie.#
M ECFI RESIDENTIAL - COMMERCIAL -
Contmetor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVING TI IH EXISTING WOOD SI IAKE ROOF,
(commencing with Section 7000)of Division 3 of the Business S Professions INSTALLING
Code and that my license is in full force and effect. 7/16-31 SOFT
1 hereby affirm under penalty of perjury one of the following twit declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided Ior by Section 3700 of the Labor Code,for the
performance of 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 perl'orntmrce of ere work Ior which this Sq.PI Floor Area:0 Valuation:$14000
permit is issued.
,U'I'1.ICA\1'CGR'I'I FIG\'PION ANN Number:36933040.00 Occupancy Type:
I certify that I have read this application mrd state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
10 building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree t0 save PERMIT EXPIRES IF WORK IS NOT STARTED
iosts,afi•and enses harmless the a City ofCupertinosato against liabilities,eofthe , WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understmidsmid will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date '
❑ O\VNER-I UILDER DEICL RATION
RF:ROOFS:
herebyaffirm(hill I not exempt Gum the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the fulluwing two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my emplo)ces with wages as their sole connrunsation• inspection.
will do the work,and the structure is not intended or offered Ior sale(Sec.7044,
Business d Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business R Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BF,TfER
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain it Certificate of Consent to self-insure lot Worker's HAZARDOUS NIATERIALS(DISCLOSURE
Compensation,as provided I'or 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 Health&Safety 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 Cupertino Municipal Code.Chapter 9.12 and the Ilealth S
Section 3700 ofthe Labor Code,for the performance of the work for which this Safety'Code Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of the work Im which this permit is issued,I shall maintain compliance with the Cupertino Nlmnicipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ileallh S Safety Code.Sections 25505.25533,and 25534.
Compensation laws of Califomia. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLIG\NI'CF-RTI FIC TION CONSTRUCTION LENDING AGENCY
I certify that I have read this application mid suite that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state Imus relating for which this permit is issued(Sec.3097,Cir C.)
to building construction,and hereby authorize 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 theCity 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
with all non-point source regulations per the Cupertino Municipal Code,Section ,U2C11 I'I'IiCI"S Ill?CL,\R.CIIUN
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional