12080072 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10082 MOSSY OAK CT CONTRACTOR:PETERSEN-DEAN INC PERMITNO: 12080072
OWNER'S NAME: EN1ERICIi ROlili 2'r AND BARBARA LT 7980 ENTERPRISE'DR DA'Z'E ISSUED:08/072012
OWNER'S PHONE.: 6509409220 NE\\'ARK,CA 94560 1110NENO:(51OH94-9982
❑ LICENSIiD CC)N'I'RACI'OR'S 1)ECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
plECll r RESIDENTIAL r COMMERCIAL
Contractor Dale
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE ROOF INSATALL PRESIDENTIAL TI.
(commencing with Section 7000)of Division 3 of the Business S Professions SHINGLES OVER 30.9 FI?LT AND CDX SIIFATHING-I ISQFT
Code and(hat my license is in fall force and effect.
hereby affirm under penalty of perjury one of the folliming Pro declarations:
1 have and will maintain a certificate of cousent 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.
I have and will maintain Worker's Compensation Insurance,as provided for by sq.W Floor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of 01e work for which this
pemlii is issued.
.\I'N Number:34232112.00 OccupancyType:
A 1'I'LIC,\N'I'CI?K'I'IPICA'rlll\
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and counq•ordinances and state laws relating
to building construction,mid hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK ISNOT STARTED
upon the above mentioned property for inspection purposes. (We)agree m save
indemnify and keep harmless the City ofCupenino 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,(he applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OR'NER-BUILDER DECLARATION 1211-ROOFS:
All roofs shall be inspected prior.to any roofing material beiig installed.If a roof is
hereby affirm(hall I nor exempt from the Contractor's License Law for one of installed wilhota first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of(he properly,or my employees with wages as their sole conlM1nsation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business R Professions Code)
I,as owner of the property,2111 exclusively contracting with licensed contractors to
construct the project(Sec.7044.Business 3 Professions Code). ALL ROOF Co\'ERINGs TO BE CLASS"A"OR BE"I.1'E14
1 hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIA1 S DISCLOSURE
I have and will maintain a Certificate 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 ralth S Safety Code.Sections 25505.25533,and 25534. 1 will maintain
performance of the work for which this peril is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth S
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Coda Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
peril is issued. contaminants as defined by the Bay Area Air Quality Management Dis'ricl I will
maintain compliance with the Cap erlino Municipal Code.Chapter 9.1_and the
I certify that in the performance of die work for which this permit is issued,I shall Health S safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation Imes of Cali limes. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code.I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCHON LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application mid slate that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and slate laws relining 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 Leader's Address
indemnity•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 peril.Additionally,the applicant understands and will comply AKCI I1'1'h:CI"S DECLARATION
with all non-point source regulations per the Cupenino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date