12080048 CITY OF CUPERTINO BUILDING PERMIT
RUILDING ADIIRFSS: 22637 ROYAL OAF:WAY CONTRACTOR:PETERSEN-DEAN INC PEIRMITNO: 12080048
OWNER'S NAME: FINNELL WILLIAM D 7980 ENTERPRISE.DR DATE ISSUED:08/07/2012
OWNER'S PHONE: 4087256732 NrNVARK,CA 94560 PI IONS NO:(510)494-9982
❑ INCENSED CON'I'RA(—I'OR'S DHCLARA TION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB 17
License Class Lia H
NIECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE SI'IAEE ROOF INSTALL PRESIDENTIAL TL OVER
(Coil] with lection 7000)of Division 3 of the Business S Profession,* 30N
Code and that my license is in full force and effect. FELT AND CDX PLYWOOD 9 SQ
1 hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a certificate ofcnnsent to self-insure for Worker's
Compensation,as provided Ibr by Section 3700 of the Labor Coda 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[lie Labor Code,Ibr the performance of die work for which this
permit is issued Sq.Ft Fluor Area:0 Valuation:$5000
APPLICANT CERTIFICATION
I certify that I have read this application laid state that the above information is APN Number:34232007.00 Occupancy Type:
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of this city m enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City ofCuperfino against liabilities.judgments. PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may aceme against said City in consequence of the
granting ofthis 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,Sectiat 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued bv: Date:
❑ OWNER-BUILDER DECLARA'T'ION
1 hereby affirm that I am exempt from the Contractor's License Law for one of RE ROOFS:
the following hyo reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
1,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials for
will do the work,and Elie structure is not intended or offered for sale(Sec.7044, .inspection.
Business&Professions Code)
1,as owner of theproperty,out exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three ALI,ROOFCOVERINGS TO BE CLASS"A"012 BEITER
declarations:
I have and will maintain a Certificate of Consenrtoself-insure for Worker's IIKLARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this pemhit is issued. I have 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 Health&Safety Code,Sections 25505,25533.and 25534. 1"ill maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&
Safely Code.Section 2553_(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 die work for which this permit is issued I shall contaminants as defied by the Ray Area Air Qualily Management District 1 will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Coda Chapter 9.12 and the
Compensation laws of California. If,alter making this certificate of exemption,I Ilealth&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent:
Ilaw-
.U'PLICAN'I'CERI'IFIGVI'ION CONSTRUCTION LENDING AGENCY
I certify that I have read this application mid state that the above information is
correct. I agree to comply with all city mill county ordinances mid state laws relating I hereby aflirtn that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon Elie above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemmnify and keep harmless the City of Cupertino against liabilides,judgnnents,
costs,and expenses which may accrue against said City in consequence of the Lender's Address
grinning of thispemmit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Sectiah ARCHITECT"S'DECLARATION
9.18.
1 understand mypl:ms shall be used as public records.
Signature Date
Licensed Professional