12090153 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10531 N BLANEY AVE CONTRACI'OR:DAN ELLIOTT'S ROOFING PFRp11-1'NO: 12090153
CO
OWNER'S NAME: IIU IISIEN-IIS1EN AND SING-CIIUNG P O 13OX 26878 DATE ISSUED:09/182012
OWNER'S PHONE: 4085597327 SAN.JOSE,CA 95159 PHONE NO:(408)559-7327
❑ LICENSED CON1'RACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r' ELECT 17 PLUiMB IJ
License Class Lie.H
i's IECH r RESIDENTIAL rJ COMMERCIAL -
Contractor Dale
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE SHAKES AND METAL,COMPLETE 35 SQ
(commencing with Section 7000)of Division 3 of the Business&.Professions
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjur 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(his permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.FI Floor Area:0 Valuation:$19000
Section 3700 of the Labor Cade,far the performance of due work for which this
permit is issued.
APN Number.31634030.00 Occupancy-Type:
APPIA CAN'T CERTIFICATION
I certify that I have read this application and state that the above information is
correct.I agree to comply with all city and count)'ordinances and state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
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. Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.Ira roof is
hereby affirm that I am exempt from the Contractor's License Lru% for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the properly,or my employees with wages as their sole compensation,
will dothe work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.1044,Business&Professions Code). At.I,ROOF COVERINGS TO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOIIS MATERIALS DISCLOSURE
I have and will maintain a Ceni Bcate of Consent(o self-insure for Worker's I have read the hazardous materials requirements under Chapter 695 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Ilenith&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued, compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilculth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(u)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
contaminants as defined by the Bay Area Air Quality\lanagement District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of die work for which this permit is issued,I shall Health&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,iter making(his cenificale of exemption,1 Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CF.RTI FICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct. I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCIIITECI"S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand np•plans shall be used as public records.
9.18.
Licensed Professional
Signature Date