12080038 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22696 ROYAL OAK WAY CONTRACTOR:PETERSEN-DEAN INC PERM IT NO: 12080038
OWN'ER'S NAME:: SULI.IVAN MICI IA1il.J ANI)CLAIRE 7980 ENTERPRISE DR DATE, ISSUED:08/07/2012
OWN'ER'S PIIONE: 4087256732 NEWARK,CA 94560 N IONENO:(510)494-9982
❑ LICENSED CON"FRACPOR'S DECLARATION BUILDING PERNIrr INFO: BLDG r ELECT r PLUMB r
License Class Lie.N
p1EC11 r RESIDENTIAL r' COMMERCIAL r
Contractor Dale
I hereby:dfirm that 1 am licensed wider the provisions of Chapter JOB DESCRIPTION: REMOVE SI LAKE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing with Section 7000)of Division 3 of the Business S Professions 30N
Code and that nn'license is in full force and effect. FELT AND CDX PLYWOOD-9 SQ
hercliv affirm u
trader penalty 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,for the
performance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area:0 Valuation:$5000
,U'I'1-ICA\I'CEH'I'I PICA'I'ION
I cenify that I have read this application and state that the above information is APN Number:34232128.00 OccupaneyType:
correct.I agree to comply with all city and county ordinances mid 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
granting of this permit. Additionally,the applicam understands and will comply WITHIN 180 DAPS OF PERMIT ISSUANCE OR
with allnon-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued bv: Date:
❑ OWNER-I UILDI?R DECLARATION
1 hereby affirm that Ilnor exempt from the Contractor's License Law for one of RE-ROOFS:
(lie following oro reasons: All roofs shall be inspected prior m 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,and the structure is 1ml intended or offered 1'or sale(Sec.7044, inspection.
Business&Professions Code)
I,as owner of the property,ain exclusively contracting with licensed contractors to Signature of Applicant: Dale:
construct the project(Sce.7044,Business&Prolcssions Code).
hereby affirm under penalty of perjury one of the following three ALI,ROOF COVERINGS-1-0 BE CLASS"A"Olt 116:1.1''11
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 of the labor Code,for the
performance of the work for which this permit is issued I have read the hazardous muterials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California I lealth S Safety Code,Sections 25505,25533,and25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which(his compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ileulth S
Sufety Code.Section_553_(4)should I store or handle hazardous material.
permit is issued Additionally,should I use equipment or devices which emit hazardous air
1 certify that in the performance of the work forwhich this permit is issued I shall contaminants as defined by the Bay Aren Air Quality Management District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Compensation laws of California. If,alier making this certificate of exemption,I Health&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:
Date:
AI'1'I.ICAN'1'CIiR'1'IpICA'I'ION CONS'(RUCTION 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 and county ordinances mid state laws relating I hereby affirm 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 the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,mod 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 ARCII ITECI"S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional