12080040 CITU OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22676 ROYAL OAK WAY CONT'RACT'OR:PETERSEN-DEAN INC PERMITNO: 12080040
OWNER'S NANIE: YU-CHU PWU 7980 FNTTERPRISE DR DATE ISSUED:08/07/2012
OWNER'S PHONE': 4087256732 NEWARK.CA 94560 PHONE NO:(510)494-9982
❑ LICENSED Cf LN'TRACI'OR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG 1- ELECT I- PLUMB [
License Class Lic.N
A1EC11 r RESIDENTIAL r COMMERCIAL r
Contractor Dale
I hereby uffirin that l:un licensed trader the provisions of Chapter •JOB DESCRIPTION: REMOVE SI[AKE ROOF INSTALL PRESIDENTIALTL OVER
(commencing kith Section 7000)of Division 3 of the Business& Professions 30N
Cude:rd that nay license is in full force and effect. FELT AND CDS PLYWOOD 9 SQ
herehy affirm under penally of perjury,one of the following ten 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.
I have and will maintain Worker's Compensation Insurance,lis provided for by
Section 3700 of the Labor Code,for the performance of Ute work for which this Sq.Ft Floor Arca:0 Valuntion:$5000
permit is issued.
,\I'I'I"I C.\NPCP:RTI FIC,\'PION AI'N Number:34232130.00 Occupancy T'ypc:
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 ordinmmes mid state Imes relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (\11c)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs.and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting oRhis permit. Additionally,the applicmd understmids and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER-RUILDER DECLARATION
RE-ROOFS:
hereby affirm[hill I am exempt from thi Cuntroclur's License Law for one of All roofs shall be inspected prior to may roofing material being installed If a roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or ofiCred for sale(Sec.7044,
Business K Prolessions Code) Signature of Applicant: Dale:
I,as owner of the Property,all)exdusivdy contracting With licensed contractors to
construct the project(Sec.7044,Business R Prol'essions Code). ALL ROOF COVERINGS TO BE CLASS"A"012 111 1-I'EIt
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's DA%ARDOUS MATERIA I S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for lire I have read the hazardous materials requirements under Chup[er 6.95 of the
performance of the work for Which this pemtit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the work for which this Safely Code,Section 25532(a)should 1 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 Area Air Quality Nlanagement 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 become subject to the Worker's Ilealth&Saf ly Code,Sections 25505.25533.and 25534.
Compensation laws ofCalifamia. If,after making this certificate ofeseniplion,I
become subject to the Worker's Compensation provisions of the Labor Code,I must O`vner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked Date:
APPLICANTCERTI FICATIO,N CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby aftiri thm there is a construction lending agency for the performance of swrk's
correct.I agree to comply with all city 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 permil.Additionally,the applicant understands and will comply nRC111'I'ISCI"S DECLARATION
all non-point source regulations per the Cupertino Municipal Code,Section
9.1& 1 understand my plans steal I be used m public records.
Signature Date Licensed Professional