12080092CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7955 SUNDERLAND DR CONTRAC'FOR: LOS GATOS ROOFING PFRMITNO: 12080092
OWNER'SNAME: KIRTLAND HENRY P 0 BOX 1726 DATE ISSUED: 08/092012
OWNER'S I'DONE: 4082571372 LOS GATOS, CA 95031 PHONE NO: (408)298-9399
❑ LICENSED CON FRACI'OR'S DECLARATION
BUILDING PERDIITINFO: 131.DC (— ELECT r PLUMB
License Class Lie.
Contractor
I hereby alarm that I am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 of the Business S Professions
Code and that limy license is in full force and effect.
hereby affirm under penalty of perjury one of the following wan declarations:
I have and will maintain a cenilicate 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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Section 3700 of the Labor Cade, for the performance of die work for which this
permit is issued.
,\I'I'I,IC,\N'I' CI?R'I'IPIC,\'I'IfIN
I certify that I have read this application laid state that the above information is
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,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit, Additionally, the applicant understands and mill comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18,
NIECli I- RESIDENTIAL r COMMERCIAL r
JOB DESCRIPTION: REMOVE EXISTING SHAKE ROOFING. INSTALL OSB
WITH
RADIANT BARRIER. 4:12 PITCH I STORY
HONE -DURATION PREMIUM LIFETIME COMP 32 SQRS.
Sq. Pt Floor Area: 0 1 Valuation: $9064
Ali\ Number: 36211012.00 1 Occupancy Ty pe:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date I Issued by:
❑ OAVNER-13111 LDER DECLARA'T'ION
I hereby affirm that I am exempt from the Contractor's License Law for one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
mill do the work, mid the structure is not intended or o0ered for sale (Sec.7044,
Business R Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project(Sec.7044,13usiness K Professions Code).
I hereby affirm under penally of perjury one of the fullnwing three
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 lot 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 the work for which this
permit is issued.
I certily thal in the performance of dic work fanvhich this permit is issued, l shall
not employ any person in any manner so as to become subject to the Worker's
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
forthwith comply with such provisions or this permit shall be deenied revoked.
\I'1'I,IC,\N I' Clilil'IPIG\'PION
I certify that I have read this application mid state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize represenmti%es of this city to enter
upon the above mentioned propeny for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs, and expenses which may acerae against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Date
Date:
.REI -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Date:
ALI, ROOF COVERINGS 9'0 BE CLASS "A" OR BEnTR
I IAZARDOUS MATERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
Califurnin Ilenlih S Safety Cnde, Sectinnx 25505, 25533, and 25534. 1 will maintain
coni plia lice mi lh the Cn pertino Municipal Code, Chapter 9.12 and the Ilealth &
Safety Code. Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality DlanagemenfDi.strict 1 will
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the
Health & Safety Code. Sections 25505, 25533, and 25534.
Owner or authorized agent:
Date:
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a construction lending agency for the performance of mwrk's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCHITECI"S DEICLARATION
I understand my plans shall be used as public records.
Licensed