12080074 CITY OF CUPERTINO 13UILDING PERMIT
Rill LDING ADDRESS: 10062 MOSSY OAK CT CONTRACI'OR:PETERSEN-DEAN INC pERMIT NO: 12080074
OWNER'S NAME: CIIEE OLIVER K 7980 ENTERPRISE DR DATEE, ISSIJED:08/07/2012
OWNER'S PHONE.: 6509409220 NENVARK,CA 94560 1'I IONE NO:(510)494-9982
❑ LICENSED CON"IRACfOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.H
pIECFI r RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm War l ant licensed under the provisions of Chapter9 JOB DESCRIPTION: REhIOVESIIAKE ROOF INSATALL PRESIDENTIALTL
(commencing with Section 7000)of Division 3 of the Business S Professions SHINGLES OVER 30N FECr AND CDX SHEATHING-1 ISQFT
Code and that lit'license is in full force acrd effect.
I hereby affirm under penalty of perjury line of the fallowing two declarations:
I have and will maintain a certificate of consent to self-insure far 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.Fr Floor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
APS Number:34232110.00 Occupancy'rype:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
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. ('Ale)agree to save
indenmify 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 Cit'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
❑ OWNER-BIIILDI9t DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exanpt from the Contractor's License Lawfor one of installed without first obtaining an inspection.I agree to remove all new materials for
the following two 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 of ercd for sale(Sec.7044, Signature of Applicant: Dale:
Business&Professions Code)
1,as owner of tile property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). AL1,ROOF COVERINGS TO IIP:CLASS"A"OR BE ITR
I hereby affirm under penally of perjury one of the following three
declarations: IIA•LARDO(1S BIATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self insure for Worker's I have read the hazardous auderials requirements under Chapter 6.95 of the
Compensation,a provided for by Section 3700 of the Labor Code,for the California Health\Safety Code,Sections 25505,25533.tad 25534. 1 will maintain
performance of the work for which this permit is issued compliance with the Cuperlino\lunicipal Code.Chapter 9.12 and the I Icalth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety.Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the perlbr lance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Arca Air Onotify Blanngemenl District 1 will
permit is issued maintain compliance with the Cuperlino Municipal Code,Chapter 9.12 mid the
I certify shat in[lie performance of die work forw'hich this permit is issued,I shall HeaDh S Safely Code.Sections 25505,25533,and 25534.
lie((cngdoy any person in any manner so as to become subject to the Worker's
Compensation laws of California, If,alter making this certificate ofexemplion,I Owner or authorized agent:
become subject 10 the Worker's Compensation provisions of the Labor Code,I must Dale:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONST RUCTION LENDING AGENCY
APPLICANTCERTI FICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application laid 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 count)'ordinances laid state Imes relating Lender's Name
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnity and keep harmless the City ol'Cupenino 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 ARCI IITF`C`l"S DECLARA'T'ION
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