12080056CITY OF CUPERTINO BUILDING PERMIT
BUILIIING ADDRI?SS: 10007 SPANISH OAK Cf
CO\ rRACI'OR: PETERSEN-DEAN INC
PERMIT NO: 12080056
OWNER'S NAME: DANIEL EDELSON
7980 ENTERPRISE DR
DATE ISSUED: 08/072012
OWNER'S PRONE: 4087256732
NEWARK, CA 94560
PHONE NO: (510)494-9982
❑ LICENSED CON"I'RACI'OR'S DECLARATION
1- 1- r
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lie. q
(-
-
M F.C11 RESIDENTIAL COi11MERCIAL
Contractor Date
hereby affirm than 1 am licensed under rhe provisions of Chapter 9
JOR DESCRIPTION: REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing with Section 7000) of Division 3 of the business S Professions
30W
PELT AND CDX PLYWOOD 1 I SQ
Code :rad that my license is in full force and effect.
1 hereby affirm under penalty of peljur) one of lite 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 lite work for which this permit is issued.
I.hm'e and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Fluor Area: 0
Valuation: $6000
Section 3700 ofthe Labor Code, for rhe performance of the work fonvhich this
permit is issued.
APN Number: 34232081.00 Occupancy Type:
\I'I'LIC.\N'I'CP:If1'I Itl CA'I'IfIN
Icerlily than I have read this application and slate that the above information is
correct. I agree to comply with all city and county ordinances and stare laws relating
to building construction, and hereby authorize representatives oflhis city to enter
upon the above mentioned property for inspection purposes. (We)agree tosave
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which toayacemeagainst Said City ill Consequence ofuw
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant understands and will comply
1 gO DAYS FROM LAST CALLED INSPECTION.
with all non -point source regularioIs per the Cupertino Nhmicipal Code, Section
9.18.
Issued by: Date:
Signature [):lie
❑ OWNER -BUILDER DECLARATION
RI: ROOFS:
herchy affirm that I am exempt front the Conlraclur's License Laufur one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is
the following mo reasons:
installed vcirho t first obtaining an inspection, 1 agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work and the structure is not intended or offered for sale (Sce.7044,
Business & Professions Code)
Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors no
construct the project (Sec.7044, Business S Professions Code),
ALL ROOF COVERINGS TO BE CLASS "A" OR IIE 17ER
hereby affirm under penalty of perjury one of the folluuing three
declarations:
I have and will maintain a Certificate of Consad to self -insure for Worker's
HAZARDOUS MATERIALS 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 [his permit is issued.
California Health S 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 Health 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 hwardous air
permit is issued.
contaminants as defined by the Ray Area Air Quality Management District I will
e work fovhich this permit is issued, I shall
I certify that in the performance of dn
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
Health S Safety Code. Sections 25505. 25533, and 25534.
Compensation Imus of California. If, roller making this certificate of exemption, I
become subject to the Worker's Compensation provisions of rhe Labor Code, 1 must
Owner or authorized agent:
forthwith comply with such provisions or this permit shall he deemed revoked.
Date:
CONSTRUCr1ON LENDING AGENCY
\rP1.1c,\N r GER ru 1crrloN
I certify that I have read this application told state that the above information is
I hereby affirm that thele is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances mid state laws relating
for which this permit is issued (Sec. 3097, Civ Q
to building construction, and hereby authorize representatives of this city to enter
lender's Name
upon [he above mentioned property for inspection purposes. (We) agree to sax
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
,\RCIII'I'ECI"S DECLARATION
w'lllt 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