12080061 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 10037 SPANISIi OAK CI' CONTRACTOR:PETERSEN-DEAN INC PERMITNO: 12080061
OWNER'S NAME: CHING AMELIA Y 7980 ENI'EItI'll ISE DR DATE ISSUED:08/072012
OWNER'S PHONIC: 6509409220 NI:NARK,CA 94560 PHONENO:(5m)494-9982
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT I- PLUMB r
License Class Lie,b
DIECFI r RESIDENTIAL r COi111DIERCLU.
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 Business S Professions SHINGLES OVER 30.Y FELT AND COX SIIEATIIING-1ISQFT
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjuryone 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 far by Sq. Ft Iloor,%rea:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of die work for which this
pennit is issued.
.V�\Number:34232084.00 Occupancy'1)pc:
.\I'I'LIG\NI'CIiR'I'I PIC.\'I'ION
I cenify that I have read this application mid state that the above information is
coffee[. I agree to comply with all city and county ordinances mid state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned proper 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 expenseswhich may accrue against said City inconsequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands mid will comply
with all non-point source regulation;per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ O\VNER-RUILDE'll DECLARATION RE-ROOFS:
All roofs shall he inspected prior to any roofing material being installed.If a roof is
I hereby affirm that 1 am exempt from the Contractor's License Lm, fur one of installed wi[ho t first obtaining an inspection,I agree to remove all new malerials for
the following Iwo reasons: inspection.
1,as owner of the property,carry employees with wages as their sole compensation,
will do the work,and the structure is not intended or of fired fur sale(Sec.7044, Signature of Appliclaw Date:
Business K Professions Code)
I,as owner of the property,ain exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business d Professions Code). ALI,ROOF COVICRINGS T'O RE CLASS"A"OR BE ITER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Cenificate 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 I Icallh S Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which[his 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 I store or handle hazardous 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 conlomimmis as defined by the Bay Area Air Quality Management District 1 will
maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of die work for which this permit is issued,I shall Health S Safety Code,Sections 25505.25533,and 25534.
not employ any person in any manner so at to become subject to the Worker's
Compensation laws ofCalifomia. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the labor Code,I must (late:
forthwith comply with such provisions or this pennit shall be deemed revoked.
CONSTRIICI'ION LENDING AGENCY
APPLICANTCERTI FICAT'ION I hereby alTinn thin there is a construction lending agency for the performance of work's
I certify that I have mad this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
coffee[.I agree to comply with all city and comity 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 pemnit.Additionally,the applicant understands and will comply ARCHITECT'S ITECf'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Scotian I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date