12080117 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 19790 AUBURN DR CONTRACI'OR:SIIADOWFAX ROOFING PERMIT NO: 12080117
OWNISR'S NAME: KAU CHEI-CIIAN I:FAL 1366 SANTA IT Ult DATE ISSUED:08110/2012
OWNER'S PHONE: 4083914826 SANJOSE.CA 95118 PHONE NO:(408)265-2490
❑ LICENSIiD CO\FRACfOR'S DEICLARATION BUILDING PERMIT INFO: BLDG F- ELECT r PLUMB r
License Class Lie.#
AIECH r RESIDENTIAL[ COMMERCIAL r
Contractor Date
hereby affirm that I am licensed trader the provisions of Chapter 9 3013 DESCRIPTION:TEAR OFF EXISTING ROOF AND APPLY IB ROOF SYSTEM
(commencing with Section 7000)of Division 3 of the Business& Professions AND GU17ERS-22 SQ
Code and that my license is in full force and effect.
herebv affirm under penalty of perjury ane 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(lie Labor Cade,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 of die work,for m hick this Sq. Ft Floor Area:0 Valuation:$14000
permit is issued.
APPLICANTCERTIFICATION ARC Number:31635014.00 Occupancy Type:
I cenify that I have read this application mid state that the above infonnalion is
correct.I 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
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 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.
Issued by: Date:
Signature Date
❑ OWNER-BUILDE,11 DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License lane for one of All roofs shall be inspected prior to any roofing material beiig installed.Ira roof is
the following two reasons: installed without first obtaining an inspection,1 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,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 13E CLASS"A"OR BE I'ER
hereb%y 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 IIA%ARDOUS MATERIALS 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 Ilealth&Safety 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 Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined try the Bay Area Air Quality INIanagement District I will
I cenify that in the performance of the 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 I leakh&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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked, Date:
APPLIC NT CFRTI FICATION CONS'I'RUCI'ION LENDING AGENCY
I certify that I have read this application mid state that time 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 mud state laws relating Ivor which this permit is issued(Sec.3097,Cir C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned properly 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 accme against said City in consequence of the
granting of this permit.Additionally,lire applicant understands and will comply ARCIII'1'PCf'S DECLARATION
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