12080050 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22617 ROYAL OAR WAY CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 12080050
OWNER'S NAAIE: JAMES DUNAWAY 7980 ENTERPRISE DR DATE ISSUED:08/072012
OWNER'S PlIONE: 4087256732 NE\\'ARK.C\ 91560 PBONF.NO:(510)494-9982
❑ LICENSED CONTRACFOR'S DECLARATION BUILDING PERMIT INFO: BLDC 1- ELECT r PLUMB r
License Class Lic.q
h1ECH r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that Into licensed under the provisions Of Chapter 9 JOB-DESCRIPTION:REMOVE SFL\RE ROOF INSTALL PRESIDENTIAL TL OVER
(coil)nmenci ng with Section 7000)of Division 3 of the Business S Professions 308
Code and that my license is in full force and effect. FECf AND CDX PLYWOOD 9 SQ
hereby affirm under penalty of perjury one of the fallowing 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•for the
performance of the work for which this permit is issued.
Phave and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ute work far vhich this Sq.Ft Flour Area:0 Valuation:$5000
permit is issued.
APPLICANT CERTIFICATION A PN Number:34232009.00 OccupancyType:
Icertify that 1 have read this application and state that the above intormation 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 far 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 accmc aeainst said Cit•in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this 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.
Issued by: Date:
Signature Date "
1 ❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I herehv affirm that 1 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 aro reasons: installed without first obtaining mn inspection,l agree to remove all new materials for
1,as owner of the property,or my employees with wages is their sole compensation, inspection.
will do the work,mid the structure is not intended oroffered for sale(Sce.7044,
Business @ Professions Code) Signature of Applicant Date:
I,as owner of the property,amexelusively contracting with licensed contractors to
construct the project(Sec.7044.Business 3 Professions Code). ALL R0017 COVERINGS TO BE CLASS"A"OR BE ITER
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 for,by Section 3700 ofthe Labor Code,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. 1 will maintain
1 have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Cade.Chapter 9.12 and the Ilealth S
Section 3700 of the Labor Code,for the performance of the work for which this Safe[) Code,Section'_553'_(a)"should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hnzardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the perfornnance of One work for which this permit is issued,I shall maintain compliance with the Cupertino Nlu aicipal Code.Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health S.Safety Code,Sections 25505.25533,and 2.5534.
Compensation Imus 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 Darr.
.U'1'hIG\N"f CT;K'I'I FIG\'PION CONSTRUC`T'ION LENDING AGENCY
I certify that 1 have read this application mid state that the above information is I hereby affirm that there is a constmction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state Imus relating for which this permit is issued(Sec.3097,Cie 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 harmless the City Of Cupertinoagainst liabilities,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
grinning of this permit.Additionally,the applicart understands and will comply ,\I2C111'I'PCI"S DFCL,U2,Vf10N
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