12080071 CITY OF CUPERTINO BUILDING PERMIT
BI11LDING ADDRESS: 10092 MOSSY OAK Cl' CONPRACI'OR:vETERSEN-DEAN INC PERMITNO: 12080071
OWNER'S NAME: WUNDERLICH MARGARET 7980 ENI EIRPRISE DR DATE, ISSIIED:08107R012
OWNER'S PIIONE: 6509409220 NEWA RK,CA 94560 PIIONENO:(510)494-9982
❑ LICENS1•ID CONFRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUNIB r
License Class Lie.t!
MECH RESIDENTIAL r. CONIDIERCIAL
Contractor Date
1 herchy affirm ilial 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVESIIAKE ROOF INSATALL PRESIDENTIAL TL
(commencing with Section 7000)of Division 3 of the Business&Professions SHINGLES OVER 304 FELT AND CDX S11EATHING-1 ISQFT
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have mrd 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 work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq. Ft Floor Area:0 Valuation:$6000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued.
ANN Number:34232113.00 Occupancy Type:
APPLICANT CERTTFIC.CIION
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city mid county ordinances mid state laws 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 18O DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of die Igo DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally, the applicant understands and w ill comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNFR-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material bcitg installed.If a roof is
I hereby affirm that I ami exempt from the Contractor's License Law formic of installed without first obtainingan inspection.I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or m}•employees with wages as their sale compensation,
will do the work,and the structure is not intended or offered for sale(Sce.7044, Signature of Applic nt: Date:
Business S Professions Code)
I,as owner ollhe property,ani exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business K Professions Code). ALL ROOF COVERINGS TO Ill,'CLASS"A"OR RP7I'1'ER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Cerliticatc of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 695 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California I Iealth S Safety Code,Sections 25505,2.5533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code.Chapter 9.12 and the Health S
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 performance of the work IDr which this •additionally,should 1 use equipment or devices which emit hazardous air
permit is issued conmminatls as defined by the Bav Area Air Quality Management District I will
maintain compliance with the Cupertino Municipal Code.Chapter 9.1_and the
I certify that in the performance of One work for which this permit is issued,I shall I lealth S Safety Code,Sections 25505.25533,and 2.5534.
not employ any person in my manner so as to become subject to the Worker's
Compensation laws of Califomia. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compcnswion provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRAIC'flON LENDING AGENCY
APPLICANT CERT'IFICAT'ION I hereby affirm that there is a construction lending agency for the performance of cork's
I certify that I have read this application and slate that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.1 agree to comply with all city and county ordinances and state paws 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 A I2CI11'I'IiCI"S IIFCLA ILCI'ION
granting of this permit.Additionally,the applicant understands and will comply
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