12080064 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRIiSS: 10009 DOVE OAR CT CON'TRACT'OR:PETERSEN-DEAN INC PERMITNO: 12080064
OWNER'S NAME: CLIFF NIAR3ORIE 11 7980 FNI'ERPRISE DR DATE ISSUED:08107/2012
OWNER'S PIIONE: 6509409220 NEWARK,CA 94560 PHONE No:(510)494-9982
❑ LICENSED CON TRACT'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUAIB r
License Class Lia H
alecll r RESIDENTIAL coMalERCL\L
Contractor Date
1 hereby affirm that I am licensed trader the provisions of Chapter JOB DESCRIPTION: REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business S Professions SHINGLES OVER 30A FELTAND CDS SHEATHING I I SQ
Code and that nor license is in full force and effect.
herelly affirm under penalt' of perjury one of the following Iwo declarations:
1 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
Section 3700 of the Labor Code,for the performance of die work for which this Sq.FI Floor Aren:0 Valuation:$6000
permit is issued.
APPLIC\\I•CERTIFICATION ,U;N Number:34232093,00 Occupancy Type:
I certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances mid state Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon theabove mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemniN and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may acerae against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. 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.
Issuer) by: Date:
Signature Date
❑ OWNIiR-BUILDER DECLARATTON
I21 ROOFS:
hereby aflinn that I 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 wilhow first obtaining an inspection,I 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 ollered for sale(Sec.7044,
Business K Prol-essions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business S Professions Code), ALL ROOF COVERINGS TO RE CLASS"A"OR BP;I-I'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 HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California I lealth 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 Ilcallh S
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should [Blore or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
I certify that in the performance of die work forwhich 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 lealth S 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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that 1 have read this application and 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 mid state laws relating for which this permit is issued(Sec.3097,Cie 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 l iabilities,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 ,\RCII I'1'FCI"S DECLARATION
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