12070218 CITY OF CUPERTINO 13UILDING PERMIT
BUILDINGADDRESS: 10226 COLBY AVE CO\I'RACI'OR:LINDY ROOFING PERMIT'NO: 12070218
COMPANY
ON'NF,R'S NAME: LHE EDMUND P AND IIELEN R 476%V TAYLOR S1' DATE ISSUED:07272012
OWNER'S PHONE: 4084767138 SAN.IOSE.CA 95110 PHONE NO:(408)286.9990
❑ LICENSED CO\FRAC`FOR'S DECLARATION BUILDING PERMIT INFO: BLDG I- ELECT r, PLUMB i-
License Class Lie.N
bIECH r RESIDENTIAL - COpL11ERC1AL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter •JOB DESCRIPTION: REMOVING THE EXISTING COMPOSITION SHINGLE
(commencing with Section 7000)of Division 3 of the Business&Professions ROOF,
Code and that my license is in fall force and effect. INSTALLING 12-31SQFT
1 hereby affirm under penaltyof perjure 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
performance of 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 perfommnce of die work for which this Sy.FI Floor Area:0 Valuation:$16000
permit is issued.
A I'I'LIC\NT'CFI2'1'1IIC\'I'ION APNNumber:31628037.00 Occupancy Type:
I certify that Ihave read this application and state that the above information is
correct.I agree to comply with all city and county ordiumices 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 applicmuunderstands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Sectiai
9.18.
Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RF;ROOFS:
1 hereby affirm that 1 am exempt from the Contrnctor's License law fur one of All roofs shall be inspected prior to any roofing material beiig installed.If a roof is
the following two reasons: installed without first obtaining an inspection,1 agree to remove all new materials for
I,as owner ofthe property,or my employees with wages as Ihcir sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contacting with licensed contactors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVF-R1NGS TO BE CLASS"A"OR BE'I;rER
I hereby affirm under penalty of perjure one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IL\LARDOUS MATFRIAIS 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
performance of the work for which this permit is issued. California Ilealth&Safely 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 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 himardaus air
permit is issued. contaminants as defined by the Iia),Area Air Quality Management District I will
I certify that in the performance oldie 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 I Iealth&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,I must Ow ner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTI FIC TION CON'SfRUCI'ION LENDING AGENCY
I certify that I have read this application Enid 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 nil city mid county ordinances Enid 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 ARCIIfI*ECI"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