12080062 CITY OF CUPERTINO BUILDING PERMIT
BUILDINC ADDRESS: 10047 SPANISH OAK CT CON'IRACI'OR:PETERSEN-DEAN INC PF,RMITNO: 12080062
O\\;NEWSNAME: ARREDOND0I7II.11317R'1'OANDMAlt'I'IIA 7980 ENTERPRISE DR DATE ISSUED:08/072012
OWNER'S PHONE: 6509409220 NEWARK.CA 94560 PHONE NO:(510)194-9982
❑ LICENSED CON-fRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT C PLUMB r
License Class Lie.q
DIISCIi r RESIDENTIAL CODIMERCIAL
Contractor Date
herchy affirm than Into licensed under the provisions of Chapter 9 JOB DESCRIPTION: RENIOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business& Professions SHINGLES OVER 309 17ELTAND CDX SHF,\TIRNG- I ISQF-f
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury ane of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided Ibr by Section 3700 of the Labor Code,for the
perfomance 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 performance of the work for which this
permit is issued.
APNNumber.34232085.00 Occupancy Type:
Al'I'LICAN'I'CISR"1'IPIC,\TION
I cenify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances wad state Imus relating
to building construction,and hereby authorize 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[tic City of Cupertino against liabilities,judgmenms, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the Igo DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulation per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ O\\'NER-BUILDER DECLARATION RF:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
I hereby affirm that I am eienupn from the Contractor's License Law"formic Of installed without first obtaining an inspection.I agree to remove all new materials for
the following"%a reasons: inspection.
I,as owner of the property,or my employees wilb wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sce.7044, Signature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,an exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR RE ITER
1 hereby affirm under penalty of perjury one of the fullouing three
declarations: HAZARDOUS MATERIALS 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,asprovided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 n'ill maintain
performance of the work for which this permit is issued. compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the Health&-
I
I have and will maintain Worker's Compensation Insurance.its provided Ibr by Safeq.Code,Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for[lie performance ol'lhe work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I will
maintain compliance with the Cupertino Nlmnicipal Code,Chapter 9.12 and the
I cenify that in the performance of the work for which this permit is issued,I shall Health&Safely Coda Sections 25505.25533,and 25534.
not employ my person in sty manner so as to become subject to the Worker's
Compensation lues of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Cmnmpensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCI'IO,N LENDING AGENCY
,U'1'I,ICAN'I'CliR'I'IFIC,\'I'RIN I hereby affirm that there is a construction lending agency for the performance of ssork's
I certify that p have read this application and state that the above information is for which this pemnit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances aid 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.(%Vc)agree to save Lender's Address
indenmify and keep harmless the City of Cupertino against liabilitics,judgments,
costs,and expenses which may acemc against said City in consequence of the
granting of this permit.Additionally,the applicator understands and will comply AKCI I I'I'ISCI"S DECLARATION
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 Professional
Signature Date