12080039 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRI?SS: 22686 ROYAL OAR WAY C'ONI'RAC'MR:11617L'RSEN-DEAN INC P ERMITNO: 12080039
OWNER'SNAME: WIIITELEYJOIiNT 79HO FNTERPRISE DIA DA'Z'E ISSUED:08/072012
OWNER'S PHONE: 4087256732 NEWARK,CA 94560 N IONENO:(510)494-9982
❑ LICIsNSED CONfRACPOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1— ELECT 1- PLUMB
License Class LiaN
hlECli r RESIDENTIAL r COMMERCIAL r
Contractor Date
1 hereby affirm that I am licensed tinder the provision,of Chapter JOB DESCRIPTION: REMOVE SI1AKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing kith Section 7000)of Division 3 of the Business S I'rofession.+ 309
Code and that my license is in full force and effect. 1717l:f AND CDX PLYWOOD 9 SQ
hereby affirm under penally of perjunone of the follo»ingill n declarations:
I have and will maintain a cert:ficate of consent to self-insure for Worker's
Compensation,as provided for.by Section 3700 of the Labor Code,for the
perfonnmec 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 Jte work for"Inch this
permit is issued. Sq.Ft Floor Area:0 \'situation:$5000
.\I'I'LIC.\\I'CIiR'1'IPICA'1'I(IN
I cenify that I have read this application and state that the above information is ANN Number:34232129.00 Occuparin.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 10 save
indemnify and keep harmless the City of Cupertinoagainst liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may uveae against said Cit'in consequence of the
granting of this permit. Additionally,the applicant understandsanmd 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:
❑ OWNER-BUILDER DLCLARATION
1 hereby affirm [hat 1 am exempt from the Contractor's License Lav for one of It b:ROOF&
the folio,ing two reasons: All roofs shall be inspected prior to any roofing material being installed If a roof is
I,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 tad the structure is not intended or offered for sale(Sec.7044, inspection.
Business&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 d Professions Code).
1 hereby affirm tinder Pennln'of perjun'one of the follu,ing three ALL HOOF COVERINGS TO BE CLASS"A"OR BETFER
declarations:
I have and will maintain a Cenificale of Consent to self-insure for Worker's HAZARDOUS MATERLU S DISCLOSURE
Compensation,m provided for by Section 3700 of the labor Code,for the
performance of the Work for which this pemit 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 Ilcalth S Safety Code,Sections 25505,25533,and 25534. 1 Will maintain
Section 3700 of the Labor Code,for theerformance of the work for Which this compliance,fill the Cupertino Municipal Code,Chapter 9.12 and the Ilealth S
F Sit rely Coda Section 25532(a)should I store or handle hazardous material.
permit is issued Addi[ionally,should I use equipment or devices which emit hazardous air
I cenify that in the performance of die work for which this permit is issued.I shall contaminants as defined by the BayArea Air Quality Ma nagemenl District 1 will
not employ any person:n any manner so as to become subject 10[he Worker's maintain compliance,fill the Cupertino Jlunicipal Code,Chapter 9.12 and the
Compensation lyes of California. If,after making this certificate of exemption.I Ilcalth&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 O`yoer or authorized agent:
Date:
APPLICANT CERTIFICATION CONSTRl1C11ON LENDING AGENCY
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 laws relating I hereby alliin that there is a construction lending agency for the performance of work's
to building construction,mid hereby authorize representatives of this city to enter for Which this permit is issued(Sec.3097,Cir C:)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the Leader's Address
granting of this permit.Additionally,time applicant understands and Will comply
with all non-point source regulations per the Cupertino Municipal Code,Secti&I ARC1IITEX-1"S DECLARATION
9.18.
I understood my plans shall be used as public records.
Signature Dale
Licensed Professional