12080068 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRIiSS: 10039 DOVE OAK CI' CONTRAC1'OR:PETERSEN-DEAN INC PEIRMITNO: 12080068
O\VNER'SNAME: [IORNINGRONAI.DCAND'I'I:IiI2YM 7980 ENTERPRISE DR DATE ISSUED:08/072012
OW'NER'S Pl IONE: 6509409220 NEV'A RK,C\ 94560 PHONE NO:(5IOH94-9982
❑ I-ICENSED CON'T'RACT'OR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDC C ELECT r PLUMB r
License Class Lie.d
DIEC11 (- RESIDENTIAL r COMMERCIAL -
Contractor Date
hereby affirm that I am licensed trader the provisions of Chapter 9 JOB DESCRIPTION`. REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business& Professions SHINGLES OVER 30.#FELT AND COX SHEATHING-1ISQFT
Code and that my license is in full force and effect.
hereby uffirm under penalty of perjury one of the following tyro 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 the per(ommnnec of the work for which this
permit is issued.
\I;N Number:34232096.00 occnpancy'fype:
,\rrl.IcnN•r chR'rn=Ic,\'r10N
I certify that 1 have read this application:rad state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construaion,amd hereby authorize representatives of this city it)enter PERMIT EXPIRES IF WORK IS NOT STARTED
the above mentioned property'for inspection purposes, (We)agree to save
indeninity,and keep harmless the City ol'Cupenino against liabilitics,jidgments, 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
❑ OWNF:R-IMILD ill DECLARATION REI-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
1 hereby affirm that I am exempt from the Contractor's License Law fur one of installed without first obtaining an inspection,I agree to remove all new materials for
the following ton 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 BETTER
1 hereby affirm under penalty of perjury ane of[tic following three
declarations: IIA7-ARDOUS MATERIALS DISCLOSURE
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&Safety 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 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 Additionally,should I use equipment or devices which call[hazardous air
permit is issued. contaminants as defined by the Buy Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Codc,Chapter 9.12 and the
I certify that in the performance of die work for which this permit is issued,I shall I lealth&Safe[_v Code,Sections 25505,25533,and 25534.
not employ any person in may manner so as to become subject to the Worker's
Compensation lases of California. If,after nmaking this certificate Ofescmption,I (honer or authorized 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.
CONSTRUC11ON LENDING AGENCY
APPLICANT CIiRTI FICTION I hereby affirm thin there is a construction lending agency for the perfonnmme of work's
I certify 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 laid state lases 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.Additionally,the applicant understands and will comply ARCII I"I'F:CI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Cade,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date