12080073 i
CITY OF CU13EIlTINO 13UILDING PERMIT
BUILDING ADDRESS: 10072 MOSSY OAK CT CONI'RACFOR:PGTFRSI--N-DGAN INC PERMITNO: 12080073
OWNEWS NAME: ALICE WICIiMAN 79811 EN'T'ERPRISE DR DATE, ISSUED:08/07/2012
OWNER'S PRONE: 6509409220 NEWARK.CA 94560 PIIONE NO:(SIU)494-9982
❑ LICENSED CONrRACf0R'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r' PLUNIR r
License Class Lie.H
M EC11 r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm[hull t am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business S Professions Sl TINGLES OVER 304 PELT AND CD\SUEATIiING-I ISQFf
Code and[hal my license is in full force and effect.
hereby affirm under penalty of perjury one of the following hyo 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[cork for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq, Ft Floor Area:0 Valu lion:$6000
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
ANN Number:34232111.00 Occupancy Type:
APPLICANT CERTIFIC ZION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and corny ordinances and state latus 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 the City of Cupertino against liabilities.judgments, 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 regulations per the Cupenino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-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 exempt from the Contractor's License Law formic of installed tcithout 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 offered far sale(Sec.7044, Signature of Applicant: Date:
Business C Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business S Professions Code). ALI,ROOF COVERINGS TO Rh CLASS"A"OR BMTER
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 Iealth S Safety Code.Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with[he Cuper[inmMunicipal Code,Chapter 9.12 and The Ilealth S
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code.Section 25532(0)should 1 since at,handle hazardous material.
Section 3700 ofthe Labor Code,for lire performance of the work for tyhich this Additionally,should I use equipment or devices which emit huzardous air
permit is issued. contaminants as defined by the[in)-Area Air Quality Management District I will
maintain compliance v,ilh the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of tie work for which this permit is issued,I shall I Iealth S Safety Code.Sections 25505,25533,and 25.534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laces of California.. If,after making this certificate of exanption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Cade,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRIK-110N LEN TNG AGENCY
A I'I'LIC,\N'I'CEK'1'1 FICA'fIfLN I hereby affirm that there is a construction lending agency for the performance of stork's
I certify that I have read this application and state that the above information is for tyhich this permit is issued(Sec.3097,Civ Q
correct. I agree to comply with all city and county ordinances and 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.(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 ARCI I ITECI"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