12080043 CITY OF CU13ERTINO BUILDING 13EIlMIT
BUILDING ADDRESS: 10074 LIBERTY OAK LN CONFRACI'OR:I'E-I'I?RSI>N-DEAN INC PERMPPNO: 12080043
OWNER'S NAME: ALDERMAN WILLIAM E AND MAROARL' 7980 F,\fERPRISE DR DATE ISSUED:08/072012
O\1'NISR'S PRONE: 4087256732 NEWARK.CA 94560 PHONE NO:(510)494-9982
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: I3LDG r ELECT I- PLUMB r
License Class Lie.d
QIECFI r RESIDENTIAL - CO\IPIERCL\1.
Contractor Date
hereby affirm that I am licensed wider floe provisions of Chapter 9 JOB DESCRI P'PION: REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing with Section 7000)of Di,inion 3 of the Business Je Professions 304
Code and that my license is in full force and effect. FELT AND CDS PLYWOOD-I ISQFT
here[)% affirm under penal!' of perjury one of the following two declarations:
1 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
peribromnce of the work for which this permit is issued.
I 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.Ft Floor Area:0 Valuation:$6000
permit is issued,
Al'I'LICAN"I'Cl?R'1'I1IC,VI'ION APN Number:34232046.00 OccupancyType:
I certify that I have read this application and slate that the above information is
correct.I agree to comply with all cit}'and county ordinances and state laws relating
to building construction,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 ol'Cupertioo against liabilities,judgments,
costs,and expenses which may ucerucagainsl said City in consequence of the WITHIN 180 DAN'S OF PERMIT ISSUANCE 012
granting of this permit Additionally,the applicant understands mrd will conmpl}' r
with all non-point source regulalions per the Cupertino Municipal Code,Section
180 DAYS F120A1 LAST CALLED INSPECTION.
9.18.
Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RP:ROOFS:
hereby affirm that I am exempt front the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beim installed.If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my cniplopecs with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
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 BE FFR
1 hereby affirm under penalty of perjury one of the following trice
Ideclarations:
have and will
IIA%ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to sell-insure for Worker's
Compensation,as provided for by Section 3700 ollhe Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which tris permit is issued. California licalth S Safety Code.Sections 25505.25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cuperlinu Municipal Code,Chapter 9.12 and the Health S
Section 3700 of the Labor Code,for the performance ollhe work for which this Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Arra Air Quality Management District 1 will
I certify that in the performance of the work(orwhich this permil is issued,l shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilcalth S Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this eenificate 01'exemption,I
become subject to the Worker's Compcnsmion provisions of the Labor Code,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLIC,\NT CERTI HCATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application mid state that the above information is I hereby affirm that there is a construction 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 construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
Staining of this permit.Additionally,the applirmt understands;aid will comply AKCIII'I'I?CI"S DECLARATION
with all non:poinl source regi lmiats per the Cupertino Municip:d Code.Seen&I
9,18. 1 understand my plans shall be used as public records,
Signature Dare Licensed Professional