12080060 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10027 SPANISIi OAK CI' CONT'RACT'OR:PETERSEN-DEAN INC PERMITNO: 12080060
O\VNRR'S NAME: JENKINS LISA D 7980 ENTERPRISE DR DA'Z'E ISSUED:08/07/2012
OWNER'S PlIONE: 6509409220 NE\VARK,CA 94560 PHONE NO:(510)494-9982
❑ LICENSED MNrfRA( If0R'S DECLARATION BUILDING PERMIIT INFO: BLDG r ELECT r PLUMB r.—
License
License Class Lic.N
MI F,CId RESIDENTIAL COMMERCIAL -
Contractor Date
1 hereby affirm Ihat I:um licensed under the provisions of Chapter9 JOB DESCRI PTION: REMOVES SHAKE R0017 INSATALL PRESIDENTIAL TL
(coil)mend ng with Section 7000)of Division 3 of the Business S Professions SHINGLES OVER 309 FELT AND COX SHEATHING I ISQFF
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following mo declarations:
I have mid 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.FI Floor,\ren:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
,U;N Number:34232083.00 Occupant)T3 pe:
A I'1'LIG\NI'CI?121'1 Irl C,\'PION
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 ordinancesand state laws relating-
to
elatingto building construction,mid hereby authorize representatives of city to cater PE12n1IT 1'sSPH2ES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino 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-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ O\\'NER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed If a roof is
1 hereby affirm that I our cxcmpl front the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following nvo reasons: inspection.
I,as owner of the property,or niy employees with wages as their sole comM1nsation,
will do the work,and the structure is not intended or offered for sale(Sec.7044. Signature of Applicant: Date:
Business R Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Scc.7044,Business R Professions Code). ALL ROOF COVIiRINGS TO BE CLASS"A"OR BE ITER
heretic affirm under penalty of perjury'one of the following three
declarations: IL\%,\ItDOUS MIATERL\IS DISCLOSURE
I have and will maintain a Certificate of Consent 10 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 l lcalth S Safely Code,Sections 255(15.25533,and 25533. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the health S
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should T store or handle ha:mrdous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Mn nagemenI District I will
maintain compliance with the Cupertino Mlunicipal Code.Chapter 9.12 and the
I certify that in the performance of die work Ibrwhich this permit is issued,I shall Hedth S Safetv 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,after nuking 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 permit shall be deemed revoked.
CONS"I'IZOC'1'I0N LENDING AGENCY
AI'1'I,IC,\N'f CFR'1'IFICA"I'ION I hereby alfimn that there is a construction lending agency for the performance of work's
I cenify that I have read this application and 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 and state laws 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
indemnity and keep harmless the City of Cupertino against l iabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the .\I2CI I I"I'FCI"S UFCI„\RA'T'ION
granting of this permit.AJditionalt•,the applicant understands and will comply
with all non-point source regulati(ns per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date