12070163CITY OF CUPERTINO BUILDING PERMIT
BIIILDINCADIIRI:SS: 131SSSTELLINGRD
CONI"RACFOR: LOS GATOS ROOFING
PERMITSO: 12070163
ONVNER'S NA\IE: ROBERTSON JOHN N AND PATRICIA
I'D I3OX 1726
DATE ISSUED: 07/202012
OW'NER'S PDONIi: 4087770302
LOS GATOS. CA 9.5031
PHONE NO: (408)298-9199
❑ LICENSED CON'fRAC'OR'S DECLARATION
r I.- r,
BUILDING PERMIT INFO: 13LDC ELECT PLUNIB
License Class Lie. t!
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RIECtI RESIDENTIAL COMMERCIAL
Contractor Dat:
I hereby affirm that I am licensed under the prurisiuns of Chapter 9
JOB DESCRIPTION: REMOVE EXISTING CEMWOOD ROOFING. USE EXISTING
(commencing with Section 7000) of Division 3 of the Business & Professions
PLYWOOD. INSTALL PRESIDENTIAL TL LIFETIME COMP.
Code and that nmv license is in full force and effect.
BY CERTAINTEED-27SQF7
hereby affirm under penalty of perjury one of the following two declarations:
I 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 the
perfomtance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Floor Area: 0
Valuation: $8886
Section 3700 of the Labor Code, for the ped'onnance of the work for which this
permit is issued.
AI'N Number: 36611104.00 OccupancyTpe:
APPLICANT CERTIFICATION
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 die above mentioned property for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino 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 thispermil. 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.
Issued by: Date:
Signature Date
"
❑ OWN R-RUILDER DECLARATION
RF.-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. If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
I, as owner of the properly, or my employees with wages as their sole compensation,
inspection.
will do the work, mid the structure is not intended or offered Ion sale (See.7044,
Business & Professions Code)
Signature of Applicant: Date:
I, as owner of the property, tan exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL ROOF COVERINGS TO BE CLASS "A" OR BE: FI'ER
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
IIA%ARDOUS NIATERIALS DISCLOSURE,
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
perfomtance of the work for which this permit is issued.
California I Icalth & S:dety Code. Sections 25505, 25533, mid 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 Health &
Section 3700 of the Labor Code, for the performance oflhe work for which this
Safety Code, Section 25532(x) should 1 store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Buy Area Air Quality $Management District I will
I certify that in the performance of the work fin-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 Worker's
I Icalth & Safety Code. Sections 25505, 25533, and 25534.
Compensation laws of California. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, 1 must
Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked.
Date:
CONS"I RUCHON LENDING AGENCY
APPLICANT CPRT'I FICATION
I cenify that I have read this application and state 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 allcity and county ordinnmes mid state laws relating
for which this permit is issued (Sec. 3097, Civ 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 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
ARCUITECI"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 Dale
Licensed Professional