12090001 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7626 KIRWIN LN CONTRACTOR:A&R ROOF EXPERTS INC PERMIT NO: 12090001
OWNER'S NAME:
SANJOSE.CA 95127 PHONE,NO:(408)314-9614
❑ LICENSED CON'I'RACI'OR'S DECLARATION
BUILDING PERMIT INFO: BLDG - ELECT r. PLUD1ft "'
License Class Lie.q
MECII — RESIDENTIAL -I COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR-OFF COMPOSITION SHINGLES AND INSTALL NEW
(commencing with Section 7000)of Division 3 of the Business&Professions CERTAINTEED PRESIDENTIAL COMPOSITION SHINGLES 25
Code and that my license is in full force and effect. SO
1 hereby affirm under penalty of perjury one of the fallowing 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.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of do,Work for which this Sq.Ft Floor Area:0 Valuation:$9000
permit is issued.
APPLICA7T1'CiiR'1'IF'IC,\']'ION APN Number:35922016.00 OccupancyType:
1 certify that I have read this application mid state that the above information is
corCCl. I agree to comply With all city and county ordimmces and state Imus relating
to building construction,mid hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City ol'Cupenino against liabilitics,judgniems,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicmn understmtds and will comply 180 DAYS FROM LAST CALLED INSPECTION.
With all non-point source regulmims per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER-1101LDF,R DIiCLARA'I'ION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License LOW for one Of All roofs shall be inspected prior to any 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
I,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 offered for sale(Sec.7044,
Business&Professions Code) Signmure of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVF,RINGS T'O BE CLASS"A"OR BETTER
hereby affirm under penally of perjury one of the following three
declarations: HAZARDOUS MATERIAI S DISCLOSURE
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 1 have read rhe hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued, California Health&Safety Code,Sections 2550.5.25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Jlunicipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of the Work for which this Safety Code.Section 25532(x)should 1 store or handle hazardous material.
Addi(ionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Area Air Quality Alanagement District I mill
I certify that in the performance of the 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 Health&Safer),Code,Sections 25505.25533,and 25534.
Compensation laws ofCalifomia. If,after making this certificate ofexemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must Owner or authorized agent:
forthwtiith comply with such provisions or this permit shall be deemed revoked. Date:
AI'1'I,ICAN'1'CER'1'IFIC,%'['ION CONSTRUCTION LIiNDING AGENCY
I cenify that I have read this application and state that the above information is I hereby affirm that(here is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances mid suite laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,mid hereby authorize representatives of this cityto 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 it;consequence of the
granting of this permit.Additionally,(he applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulmiots per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional