12090134 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10547 FELTON WAY CONTRACTOR:MAXIMUM ROOF CARE PERMIT NO: 12090134
CORP
OWNEXSNA111E: HU KENNE'FIi C AND SANDRA Y 1182 OLIVE BRANCH LN DA'Z'E ISSIIF-D:09/142012
OWNER'S PHONE: 4087027339 SAN JOSIS,CA 95120 PHONE NO:(408)141-0933
❑ LICENSED CO1N'1'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG I' ELECT rl PLUMB Cl
License Class Lic.9 M [ rf ri
ECII RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVING SHARE,ALREADY HAS PLYWOOD UNDER
(commencing with Section 7000)of Division 3 of the Business&Professions Ti IE
SHAKE,INSTALLING 30 LB.FELT AND 33 SQ
Code and that my license is in full force and effect. CERTAINTEED LANDMARK TL SHINGLES ICBO D3462
I hereby affirm under 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.
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 Sq.Ft Floor Area:0 Valuation:$13706
,%I'PI-ICAN'1'CERTIFICATION
I certify that I have read this application and stale that the above Information Is AI'N Number:35918012,00 Occupancy Type
correct.I agree to comply with all city and county ordinances and state lows 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 hamJessthe City ofCupertino against habilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting ofthis permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulatims per the Cupertino Municipal Code.Secti0a 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date Issued by: Date:
❑ OWNER-RUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following 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,and the structure is not intended or offered for sale(Sec.7044, inspection.
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044.Business&Professions Code). -
hereby affirm under penalty of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BETFER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IIA'J.ARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
1 have read the hazardous materials requirements25533,and
Chapter 6.95 of the
performance of the work for which this permit is issued
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safety Code,Sections_5505,_5533,and 25534. I will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Section 3700 of the Labor Code,I'or the performance of the work for which this Safety Cndr.Section 25532(a)should I store or handle hazardous material.
permit is issued Additionally,should I use equipment or devices which emit hazardous air
I certify that in the performance of die work forwhich this permit is issued I shall contaminants as defined by the,Bay Area Air Quality Management District 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 Cal ifomin. If,after making this certificate of exemption,I Health&Safety Coder 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:
APPLICSNI'CERTIFIC\TION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and smte laws relating I hereby affirm that there is a construction lending agency for the performance of cork'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,and 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 ARCHITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional