12070193CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 1061 NOVEMBER DR
OWNER'S NAME: RIDDLE RALPH W 1R AND BEVERSTEIN RO
O\\ti ER'S PI ION E: 4088923342
❑ LICENSED CON TRACI'OR'S DECLARATION
License Class Lie.4
Contractor Date
hereby affirm that 1 am licensed tinder the provisions of Chapter 9
(commencing with Section 7000) of Di%ision 3 of the IIIJAI x5 & Professions
Code and thin in% license is in full force:md effect.
I hereby affirm under penalty of perjury one of the following two declarations.
I have and will maintain certificate of consent to self insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance, as provided for b%
Section 3700 of the Labor Code, (or Unc pefomnance of the work far which this
permit is issued.
AI'1'LICAN'I' CEIt'1'IFICA'I'ION
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 relining
to building construction, and hereby authorize representatives of this city to enter
upon tie above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs, and expenses which may aceme 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
9.18.
CONTRACT OR: MANADA ROOFING INC PERMIT NO: 12070193
1593 INDUSTRIA. PKW'1' W DME ISSUED: 07242012
BAYWARD. CA 94544 Pl1ONENO:(510)780-9517
BUILDING PERDIIT INFO: BLDG F7 ELECT 1- PLUMB r
NIECII r RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: REMOVE OLD SHAKE ROOF AND INSTALL NEW
PREDIDENTIAL
SIiINGLES-30SQFr
Sq. Ft Floor Area: 0 1 Valuation: $16000
APN Number: 36216013.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date I
Issued by:
❑ fl\VNER-RUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Lae' formic of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
Will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contactors to
construct the project(See.7044, Business & Professions Code).
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insurc for Worker's
Compensation, as provided for by Section 3700 of die 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, I'or the perfommnce of the work for which this
permit is issued.
I certify that in the performance of the work forwhich this permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes ofCali(omia. If, alter making this certificate ofexemption, I
become subject to the Worker's Compensation provisions of the Labor Code. I must
forthwith comply with such provisions or this permit shall be deemed revoked.
APPLICANT CE TI FICATION
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 Imes 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
indenmify and keep hamdess the City of Cupertino against liabilities. judgments,
costs, and expenses which may aceme ngainst said City in consequence of the
granting of this permit. Additionally, the applicant understands and %% ill comply
with all non -point source regulaticns per the Cupertino Municipal Code, Section
9.18.
Date:
RF. -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of
Date:
ALL ROOF COVERINGS TO BE CLASS "A" OR BETITR
IL\-/.AltDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California IIca lth & Safety Code, Sections 25505, 25533, and 25534. 1 will niai nm in
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Health &
Safety Code, Section 255320q should 1 store or handle hazardous material.
Additionally. should I use equipment or deices which emit hazardous air
contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
Ieallh & Safety Code, Sections 25505. 25533. and 25534.
Owner or authorized agent:
Der.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
ARCIUTECI"S DF:CLARXTION
I understand my plans shall be used as public records.
Date I Licensed