12080070 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10059 DOVE OAK CT CONTRACI'OR:PETERSEN-DEAN INC PERMITNO: 12080070
OWNER'SNAME: KENTGRINDSTAF17 7980 ENTERPRISE DIE DATE ISSt1ISD:08/072012
OWNEWSPIIONE: 6509409220 NEWARK,CA 94560 PHONE NO:(510)494-9982
â LICENSED CON 1FRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELIiCT rl PLUMB r
License Class Lie.b
NEC11 RESIDEN"1'LV. COMMERCIAL
Contractor Dale
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE Sl LAKE ROOF INSTALL PRESIDENTIAL TL
(commencing,,ith Section 7000)of Division 3 of the Business S Professions SHINGLES
Code and(hat my license is in full force and effect. OVER 30N FELT AND CDS SIMATHING-1 ISQFT
hereby affirm under penalty of perjury one of the following oro 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.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of die work for which this Sq.FI Flour Area:0 Valuation:$6000
permit is issued.
APPLICANTCERTIF'IC\'1'ION AIS\Number:34232098.00 Occupancy II,ypc:
I certify that 1 have read this application and slate that the above information is
correct. I agree to comply with all city and county ordinances and state Imes relating
to building consimclion,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which may acerae against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply z
ith all non-point regulations per the Cupenino Municipal Code, 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Dale:
â OWNER-BUILDER DECLARA'T'ION
RE-ROOFS:
hereby affirm that I aun ecenmpl front the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
rhe following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the propeny,or my employees with agesas their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature ofApplicant: Date:
I,as owner of(he property,am exclusively contracting with licensed contractors to
construct the project(See.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE'l-117R
I hereby affrn under penally of perjury one of the fallowing three
declarations:
I have and will maintain a Certificate of Consent to sell'-insure for Worker's DA%ARDOIIS MATERIALS DISCLOSURE.
Compensation,as provided for by Section 3700 of the Labor Cade,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued California Health S Safely Code,Sections 25505,25533,and 25534. 1 will inainlain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cuper(iau Nlunicipal Code,Chapter 9.12 and the Ileallh S
Safely Code.Section 25532(0)should 1 store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance of[lie work for which this Additionally,should I use equipment or devices m'hich entl hazardous air
permit is issued. c011taminan(s as defined by the Ray Area Air Qualily Nlanagrnctrl District I will
I certify that in the perfomrance of die work for which this permit is issued,I shall maintain cont pliance %ilh[lie Cupertino Municipal Code.Chapter 9.12 and the
not employ any person in any manner soils to become subject to the Worker's Health y Safely Code,Sediams 25505,25531 and 25534.
Compensation laws ofcnlifomia. If,after making this certificate of exemption,I
r Ou mer or authorized agent;
become subject to the Rorker's Compensaion provisions of Labor Code.I muss fâ˘
forthwith comply with such provisions or this permit shall be deemed revoked Date
.\I'1'hIGW'I'CIiR'1'I FIG\'PION CONSTRUCTION LIENDING AGENCY
I certify that I have read this application mid state that the above information is I hereby affirm that there is a consinnetion lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building constmetion,and hereby authorize representatives of this city to enter Leader's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep hamnless the City of Cupenino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applica i understands and will comply ,\ItCI l I"I'ISCI"5 DECLARATION
all non-point source regulations per the Cupenino Municipal Code,Section
9.18. 1 understand try plans shall be used as public records.
Signature Date Licensed Profemional