12080123 CITY OF CUPERTINO 13UILDING PERMIT
Ii11ILDINGADDRESS: 20363CLIFDEN WAY CONTRACFOR:TI IF HOME PFRMITN0: 12080123
IMPROVEMENT SOURCE INC
OWNER'S NAME: TSUKAMOTO MINORU AND KYOKO 1400 COLESL\NAVE.FfE1115 DATE. ISSUED:08/132012
OWNIiR'S PIIONF: 4082574171 SANTA CLARA.CA 95050 PHONE NO:(408)567-9710
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.d r 1-1r
01ECH RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE F-XSISTING WOOD SHAKE ROOF REPLACE
(commencing with Section 7000)of Division 3 of the Business S Professions WITH
Cade and that my license is in full force and effect. COMPOSITION-26 SQ
here[),-affirm under penalty of perjury one of the following two 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,ter 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 the work for which this
permit is issued. Sq.Ft Floor Area:0 Valuation:$15000
APPLICANTCERTIFICATION
I certify that 1 have read this application mid state that the above information is APN Number:36937009.00 Occupancy T'ypc:
correct. I agree to comply with all city and county ordinmices and state Imes 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
indenmitjr and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may acerae against said City.in consequence of the
granting of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued bv: Date:
❑ OW'N ISR-BUILDER DECLARATION
hereb' affirm that I am exempt from tire w e Contractor's License Lafor one of RF-ROOFS:
the fulluwing two reasons: All roofs shall be inspected prior to my roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,1 agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sce.7044, inspection.
Business R Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business d Professions Code),
hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUSMATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the labor Code,for the
performance of the work for which this permit is issued. I hays read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth S Safely Code.Sections 25505.'_5533,and'5534. 1 mill maintain
performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.1_and the Ilealth S
Section 3700 of the Labor Cade,for the
p Safety Code,Section 25532(a)should I store or handle hazardous material.
permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this pemtit is issued,I shall contaminants as defined by the[lay Area Air Quality Management District I wit]
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Compensation laws of California. If,alter making this certificate of exemption,I Health S Safety Code,Sections 25505,25533.and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,1 must
forthwith comply with such provisions or this permit shall be deemed revoked. Oa ner or authorized agent:
Datc:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and county ordinances mid state laws relating I hereby affirm thm there is a construction lending agency for the performance of vork's
to building construction,mid hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against l iabil ities,judgments,
costs,and expenses which may acerae against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCII ITTSCPS DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional