12080046 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10094 LIBERTY OAR LN CONTRACI'OR:PET'ERSEN-DEAN INC 1'ERMITNO: 12080046
OWNEIVS NAMEI: MEAD DALE F ANDJANICE K 7980 ENTERPRISE III? DA'Z'E ISSUED:08/0711012
OWNER'S PlIONE: 4087256732 NEWARK,CA 94560 PHONE NO:15110494-9982
❑ LICENSED CONI'RAC-fOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.'
pIECIT - RESIDENTIAL, COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TLOVER
(commencing with Section 7000)of Div is inn 3 of the I3 usiness S Professions 308
Code and that Inv license is in full force and effect. FELT'AND CDS PLYWOOD-I 1 SQPr
hereby affirm under penalty of perjure one of the following boo 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 work for which this permit is issued.
I hare and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work far which this Sq,FI Floor Area:0 Valuation:$6000
permit is issued.
APPLICANTCERTI FICATION APN Number:34232048.00 occupancy"Type:
I cerlily that I have read this application and scale that the above information is
correct.I agree to comply with all city and county ordinances laid stale 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 of Cupenino against liabilities,judgments,
costs,and expenses which may licence against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
❑ - OWNER-BUILDER DECLARATION
RP:ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material bcilg installed If a roof is
the following two reasons: installed wilhou first obtaining an inspection,I agree to remove all new materials for
I,as owner of the property,or my employees with wages as their sole compensation, inspection,
will do the work,land the structure is not intended or offered for sale(Sce.7044,
Business R Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business R Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"012 BEYfElt
1 hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE'
Compensation,as provided Corby Section 3700 ol'the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance oldie work for which this permit is issued California Ileal lh S Safely Code.Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as.provided for by Compliance with tine Cupertino Mu nicipal Code.Chapter 9.12 and the I lcallh S
S:dely Code.Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should 1 use equipment or devices which call[hazardous air
permit is issued. contaminants as defined by the Ray Arcu Air
Quality\Immgemcnl District 1 will
I certify that in the performance of die work Iorwhich this permit is issued I shall maintain compliance with(lie Cuperlino Municipal Code,Chapter 9.12 and the
not employ any person in any nnanner so as to become subject to the Worker's health S Safety Code,Sections 25505.25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the labor Code.I must Ow tier or authorized agent:
forthwith comply with such provisions or this permit shall be deenned revoked. hate'
APPLICANT CERTIFICATION CONST'RUCT'ION LENDING AGENCY
I certify that I have read this application and state that the above infomiaion 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 mid 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 hornless the City of Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ,\ItCI I I"I'I'CI"S DFCL,\R,\"PION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional