12080042 CITY OF CUPERTINO BUILDING PERMIT
RUILDINC AIIIIRESS: 22656 ROYAI-OAF:WAY CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 12080042
O\YNER'S NAME: KANTERS ADRIANUS AND IANE'I'JE 79811 ENTEIRPRISE DR DA'Z'E ISSUED:08/07[)012
OWNER'S P lIONIi: 4087256732 NE\1'ARK,CA 94560 PIIONF.NO:(510)494-9982
❑ LICENSED CCOM'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.q
RIECII RESIDENTIAL - COi11D1ERCL\L
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SIIAKE ROOP INSTALL PRESIDENTIALTL OVER
(commencing with Section 7000)of Division 3 of the Business S Professions 30N
Code an(]that nm license is in full force and effect. PELTAND COX PLYWOOD 9 SQ
hereby affirm under penally of perjury one of the following two declarations:
I have and will maintain a cenificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
perfammnce 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 ate work for which this Sy. Ft Ploor,\real:0 Valuation:$3000
permit is issued.
APPLICANT CERTIFICATION AI;N Number:34232132.00 Occupanq Type:
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 and state Imus 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 aceme 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.
wish all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARA'T'ION
RE:ROOFS:
1 hereby affirm that 1 am exempt from the Contractor's License Low for one of All roofs shall be inspected prior to any roofing material lacing installed If a roof is
the following Iwo reasons: installed without first obtaining an inspection,I agree to remove all new materials for
I,as owner of the properly,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is nal intended or offered for sale(Sce.7044,
Business&Professions.Code) Signature of Applicant: -Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business& Professions Code). .\1,1,ROOF CO\'1?ItINCS'I'fl BE CLASS \"OR ISIS I-I'IiR
herebv affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate ofConsent to self-insure for Worker's Il\%,ARIH)l1S JI,VI'lilt h\1 ti DISCLOSURE
Compensation,as provided d for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
perfommnnce of the work for which this permit is issued California Health S Safely Code.Sections 25505,25533,and 2553.1. 1 will maintain
I have and will maintain.Worker's Compensation Insurance,as provided for by compliance with the Cupertino Alunicipal Code,Chaptrr 9.12 and the Health S
Section 3700 of the Labor Code,for the performance of the work for which this Safer Code,Section 25532(x)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Arca Air Quolily Management District I will
I certify that in the performance of die 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 became subject to the Worker's Ilealth J 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 deenmed revoked. Dale:
APPLICANT CERTIFICATION CONS'TRIICIION LENDING AGENCY
I certify that I have read this application and state that the 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 cit and county ordinances and 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 property 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 accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ,ARCIII'I'F.CI"S UFCL,A RA"PION
with all non-point source regulations per the Cupertino Municipal Code,Sectiam
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional