12080047 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10104 LIBERTY OAK LN CONTRAC'MR:PETERSEN-DLAN INC PERMIT NO: 12080047
OWNER'S NAME: DANNY YU 7980 ENI'I:RPRISE DR DATE ISSUED:08/07/2012
OWNER'S PHONE: 4087256732 NEVA RK.CA 94560 PHONE NO:(510)494-9982
❑ LICENSED CONI'RACI' IMS DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
DIECII r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing,,ith Section 7000)of Division 3 of the Business S Professions FELT AND CDS PLYWOOD
Code and that mr license is in full force and effect. FE
hereby affirm under penalty of perjury one of the following two declarations:
I have:rad will maintain a certificate of consent 10 self-insure for Worker's
Compensation,as provided for by Section 3700 of tic 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
Section 3700 of the labor Code,for the performance ofdie work for which this Sy. Ft Floor Area:0 Valuation:$6000
permit is issued.
A I'I'LIC.\N'I'CER'I'I FICA'fIt LN APN Number:34232049.00 Occupancy Type:
I certify that I have read this application mid state thin the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,mid 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 Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAN'S OF 13ERNIIT ISSUANCE OR
granting of this permit. Additionally,the applicant underslmidsand 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:
❑ ON'N IiR-8111 LI7lilt IIECI.,\IL\'PION
RF:ROOFS:
hereby affirm that I am exempt front the Contractor's License Lao file one of All roofs shall be inspected prior to any roofing material being 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 employees with wages as their sole comM1nsation, inspection.
will do the work,mid the structure is not intended or oHired for sale(Sec.7044,
Business x Professions Code) Signature of ApplicanC Date:
[,as owner of the property,ani exclusively contracting with licensed contractors to
construct the project(Sec.7044,13usiness.Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby afirni 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 ILVLARDOUS MATERL\LS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California I lealth 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 the Cupertino Municipal Code,Chapter 9.12 and the Health S
Section 3700 of the Labor Code,for die performance ofthe work for which this Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Additionally,should 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Arca Air Quality Management District I will
I certify that in the performance of One work for which this permit is issued,I 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 (lealth S SafetyCode.Sections 25505.'_5533,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 On ncr or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked (late'
APPLICANT CERTI FIC TION CONSTRUCF10N LENDING AGENCY
I certify that I have read this application mid state that the above infomntion 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 count'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 N;mte
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,Judgnwnls, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
grinning of this permit.Additionally,the applicant understands and will comply ,UiCI II'I'IiCI"S DF:CL,\H,\!'ION
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