12080041 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRFSS: 22666 ROYALOAK WAN' CONTRACI'OR:PETERSEN-DEAN INC PERMIT NO: 12080041
OWNER'S NA\IF.: LEE VICI'OR AND MEI 7980 ENTERPRISE DR DATE ISSUED:08107/2012
OWNER'S PHONE: 4087256732 NEWARK.CA 94560 PHONE NO:(510)494-9982
❑ LICENSED C0N`fRACI'0It'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.N
Mec14 C RESIDENTIAL r coMMeltclAL r
Contractor Date
hereby affirm that 1 am licensed trader[tic provisions of Chapter 9 JOB DESCRIPTION:RE.-MOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing wilh Section 7000)of Division 3 of the Business J Professions 30N
Code and [hal nn'license is in full force and effect. FELT AND COX PLYWOOD-9 SQ
I herebw affirm under penally 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,I'or[he
perlmmance of the work far which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the pertormance of die work tom which this
permit is issued. Sq.Ft Floor Area:0 Vuluation:$5000
.U'1'LICAN'1'CEltl'I FIGCI'ION
I certify that I have read this application mid state that the above information is AM Number:34232131.00 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 to enter _
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT .STARTED
costs,and expenses which may accrue against said City in consequence of the
gmnting of this permit. Additionally,the applican 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 by: Date:
❑ ONVNER-I UILDER DECLARATION
1 hereby affirm(hat I am exempt front the Contractor's License Law for one of RF:ROOFS:
[he following neo reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the properly,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(Sec.7044, inspection.
Business S Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business S Professions Code).
1 hereby affirm under penalty of perjuryone of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations:
1 have and will maintain a Certificate of Consent to self-insure for Worker's IIA%ARDOOS MATERIALS 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 hate 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 S Safety Code,Sections 25505.25533.and 25534. 1 will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.1_and the Health S
p Safely Code,Section 25532(x)should I store or handle hazirdous 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 pemnit is issued,I shall con lam inants as defined by the Bay Area Air Quality Nlanagement District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino AI unici pal Coda Chapter 9.12 and the
Compensation laws of California. If,after making this cenifieile of exemption,I Ilealth S Safely Code.Sections 25505.25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I oras(
forthwith comply with such provisions or this pemnit shall be deemed revoked. Owner or authorized agent:
Date:
APPLICANT CERTIFICATION CONS'IRUCITON LENDING AGENCY
1 certifthat 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 laws relating I hereby affirm that there is a coistmetion lending agency for the performance of work's
to building conametion,End hereby authorize representatives of this city to enter for which this permit is issued(Sea 3097,Civ Q
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnity and keep harmless the City o'Cupertino against liabilities,judgmen[s,
costs,and expenses which may accrue 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 ARC! ITECI"S DECLARATION'
9.18.
I understand try plans shall be used as public records.
Signature Date
Licensed Professiornal.