12080066 CITY OF CUPERTINO BUILDING PERMIT
BUILIIINGADDRIiSS: 10019.DOVEOAKC' CONTRACI'OR:PETERSLN-DEAN INC PERMITNO: 12080066
OWNER'S NAME: CALGIIER PAUL F ET AL 7980 ENTERPRISE DR DA'Z'E ISSUED:08/0712012'
OWNER'S PHONE: 6509409220 NEWARK,CA 94560 PHONEN'O:(5In)494-9982
❑ LICENSED CON"IRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUAiB r
License Class Lie.N
AIECH "- RESIDENTIAL CONIDIERCL\L
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Rusiness& Profes5lmns SHINGI.FS OVER 305 FELT AND COX SHEATHING I I SQ
Code and that env license is in full force and effect.
hereby affirm under penalty of perjury 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 the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for die performance of the work for which this
permit is issued.
ANN Number:34232094.00 Occupancy Type:
AI'I'LICA\1'CEI2'I'IFIC,\'1'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 stale Imes relating
to building construction,and hereby mnhorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City ofCupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-paint source regulations per the Cupertino Municipal Code,Section
9.18. Issued bv: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection.I agree to remove all new materials for
the following Iwo reasons: inspection.
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, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE'17ER
hereby amen under penalty of perjury one of the following three
declaraliuns: HAZARDOUS BI,\9'I?KLUB IIISCLOSURIi
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safely Code,Sections 25505,25533,and 25534. 1 will nmintuin
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the I lealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of'the Labor Code,for the performance of the work for which this Additionoll%,should I we equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality\lanagennent District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of die work f'onehich this permit is issued,I shall Health&Safety Code.Sections 25505,25533.and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,alter making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this pemnit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLIC.xN"I'CER'I'IFIG\"PION I hereby affirm that there is aconswction lending agency for the performance of work's
I certify that I have read this application mid state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances mid state Imus relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs.and expenses which may accrue against said City in consequence of the
granting of this permit.Additionafly,the applicant understands and will comply ARCBITECf'S DECLARATION
with all non-point source regulations per the Cupcnino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date