12080067 CITY OF CUPERTINO BUILDING PERMIT
III11LDING ADDRESS: 10029 DOVIi OAK C'ICONTRACTOR:PETFRSEN-DEAN INC PERMIT NO: 12080067
O\\'NER'S NAME: GOMEZ DAVID 7980 ENTERPRISE DR DATE, ISSUED:08/072012
OWNER'S PHONE: 6509409220 NEWARK,CA 94.560 PIIONE,NO:(516I494-9982
❑ LICENSED CO\"IRACI'OR'S DECLARA'T'ION BUILDING PERI IT INFO: BLDG r ELECT r PLUMB r'
License Class Lie.N
dlECli r RESIDENTIAL - COMMERCIAL
Contractor Date
I hereby affirm that lam licensed under file provisions of Chapter 9 J013 DLSCRI PTION: REMOVE S13AKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business S Professions SII INGLES OVER 30k 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 two declarations:
I have and will maintain a cenificate 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 Flour Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the perfommnce of One work for which This
permit is issued.
AI'N Number:34232095.00 Occupancy Type:
APPI,Ic\N'r CF,R'rIPICA'I'ION
I certify that I have read this application and state that the above infomnahion is
correct.I agree to comply with all city and county ordinances aid state Imus relining
to building construction,and hereby authorize representatives of 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 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 mid will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ O\\'NIiR-Iil1lLUliR DIiCL.\13.\'PION RF.ROOFS:
All roofs shall be inspected prior to any roofing material being installed Ira roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining ah inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the properly,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for s le(Sec.7044. Signature of Applicant: Date:
Business R•Professions Code)
I,as owner of file property,am exclusively contracting with licensed contractors to
constmct the project(Sec.7044,Business d Professions Code). ALL ROOF COVERINGS TO Illi CLASS"A"OR RF,TI'F,R
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATTRIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's T heye read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 critic Labor Code,for the California Il cut til S Safely Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealfh S
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 ofthe Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. con mm ilia nls as defined M'the Ilan Area Air Quality Management District 1 will
maintain compliance with the Cupertino Ntunicipal Code,Chapter 9.12 and the
I certify ilial in the performance of the work for which 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 die Worker's
Compensation laws of Califamia. If,afler making dais certificate ofexennption•I Owner or emhorized agent:
become subject to the Worker's Compensation provisions of the Labor Code.I most Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
A1'I'LIC.\NT'CP:R'I'IPICA'I'I(IN I hereby affirn that there is a construction lending agency for the performance of work's
I certify that I have read this application mid state that the above infomhation is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances mid stale 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
indemnify and keep harmless the City of Cupertino against Iiabilitics,judgnlents,
costs,and expenses which may accrue against said City in consequence of the ARCI11'I'IiCI"S DECLARATION
of this permit.Additionally,the applicant anderstands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Prufemiunal
Signature Dale