12080054 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22577 ROYAL OAK WAY CONTRACTOR:PETERSEN-,DEAN INC PERMIT NO: 12080054
OWNER'S NAM B: DREEN KAREN A 7980 EN 1TRPRISF DR DATE ISSUED:08107/2012
OW'NER'S 1.11ONE: 4087256732 NEWARK.CA 94560 11I01NE NO:(510)494-9982
❑ LICENSED CONTRACTOR'S DI?CLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.N
1\IECII r RESIDENTIAL r COMMERCIAL r
Contractor Date
I hereby affirm that tam licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing with Section 7000)of Division 3 of the Business&Professions 30d
Code and that my license is in full force and effect. FEIN'AND CDX PLYWOOD.9 SQFT
1 herebyaffirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure far Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance of the work for which this pemnit is issued.
I have and will maintain Worker's Compensation Insurance,as providedfor by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Arra:0 Valuation:$5000
Permit is issued.
API'LIC\NI'Ch;RI'II'ICA'TION ANN Number:34232013.00 Occupancy!)pe:
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
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 Cil) of Cupertino against liabililics,judgmenls,
casts.and expenses which may accrue against said City in consequence ofthe WiTHiN 180 DAYS OF PERMIT ISSUANCE OR
granting ofthis permit. Additionally,the applicant understands mid 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: Dale:
-
❑ O\\'NER-BUILDER DECLARATION
RF--ROOFS:
1 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 being installed.If a roof is
the following two reasons: installed without fust obtaining tar 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,mid the structure is not intended or offered for sale(Sec.7044,
Business 3 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 TORE CLASS"A"OR BrTFFR
hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's DA'LARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 ofthe Labor Cade,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code.Sections 25505,25533.and 25534. I sill maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Jl unici pal Code.Chapter 9.12 and the I lealth&
Safety Code,Section 25532(a)should I.store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contamimmts as defined by the Ray Arca Air
Quality Management District 1 will
I certify that in the performance of die work form-hich this permit is issued,.I shall maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
not employ an)'person in any manner so as to become subject to the Worker's Health&Safety Coda Sections 25505.25533,and 25534.
Compensation laws o1 COlifornia. If.after making this certificate of exemption,I
become subject to the Worker's Compensation provisions ofthe Labor Code,I must Owner or authorized agent:
forthwith comply with such,provisions or thispermit shall be deenied revoked. Date'
APPLICANT CI?R'I'IFIC\'IION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affnrn that there is a construction lending agency for the perfomtance 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 properly for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Leader's Address
costs,and expenses which may accrue against said City in consequence ofthe
grinning of this permit.Additionally,the applicant understands and will comply ,\RCI I ITF,CI"S DECLARATION
with all non-point source regulatiams per the Cupertino Municipal Code.Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional