12070154CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22343 MC CLELLAN ILD
CONTRACTOR: LOS GATOS ROOFING
PERMIT NO: 12070154
O\YNER'S NAME: WEST JAMES AND SANDRA D
P O BOX 1726
DA'Z'E ISSUED: 0 7/1 92 0 1 2
OWNER'S POONE: 4084722665
LOS GATOS, CA 95031
PHONE NO: (408)298-9199
❑ LICENSED CONIRACI'OR'S DECLARATION
F_ r
BUILDING PERtIN11T INFO: BLDGELECT PLUMB
License Class Lie. q
r — -
p1ECF1 RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9
.1013 DESCRIPTION: REMOVE EXISTING ROOFING, USE 17XISTING PLYWOOD
(commencing with Section 7000) of Division 3 of the Business S Professions
DECK, INSTALL WOODCRES'f COMP. BY OWENS CORNING.
Code and that nn' license is in full force and effect.
17 SQ.(000SE R GARAGE)
I hereby aff rat under penalty of perjuryour of (lie 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
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sy. Ft Floor Area: 0
Valuation: $7613
Section 3700 of the Labor Code, for the performance of die work for which this
permit is issued.
AI'N Number: 35705004.00 Occupmtev Type:
APPLICANI'CF,R'I'IFICATION
I certify that I have read this application and state that the above information is
correct. 1 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
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 this permit. Additionally, the applicant undcrstandsand 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 [)me
❑ OWNER-BtII LD FIR DECLARATION
RE -ROOFS:
1 hereby affirm that 1 am exempt from the Contrnnor'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
1, as owner of the property, or my employees with wages as their sole comlinsation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
Signature of Applicant: Date:
I, as ownci of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business K Professions Code).
ALL ROOF COVERINGSTO BE CLASS "A" OR BF,'FITR
1 hereby affirm under penalty of perjury one of the following three
declarations:
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
1 hove read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Ilealth S Safety Code, Sections 25505, 25533, and 25534. 1 will mainain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Ntunicipal Code, Chapter 9.12 and the Ifealth S
Section 3700 of the 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 Aren Air Quality Ma nagentent 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 Worker's
Ilralth 3 Safety Code, Sections 25505,'_5533, and 25534.
Compensation laws of Cali fornia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owncr or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked.
Date'
CONSfRUCFION LENDING AGF;NCY
A 1'1'1.1 CANT CERTI FICYf10N
I certify that I have read this application mid state that the above information is
1 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 mond 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 acerae against said Cit' in consequence of doe
granting of this permit. Additionally, the applicant undersumds and will comply
,\RCI I I'I'I?CI"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