12090145 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10451 DAVISON AVE CONTRACTOR:SOUTH VALLEY ROOFING PERMITNO: 12090145
INC
OWNER'S NAME: 2767 AIELLO.DR DATE ISSUED:09/172012
OWNER'S PHONE: SAN.IOSF„CA 95111 PHONE NO:(
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG [ ELECT IJ PLUMB r
License Class Lie.N
r Cl
(-1
NIECH' RESIDENTIAL COMMERCIAL
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE ONE LAYER OF EXISTING MEDIUM SHAKE,
(commencing with Section 7000)of Division 3 of the Business&Professions INSTALL
Code andthat my license is in full force and effect. 25 SQRS,7/16"RADIANT BARRIER OSB 301.6 FELT,
CERTAINEED PRESIDENTIAL TO
1 hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of 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 perfommnce of die work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$13200
AI'PLICAN'f CER'1'IpICATION
I certify that I have read this application mid state that the above information is APN Number.36913049.00 Occupancy Type:
correct.1 agree to comply with all city and county ordinances and state laws relating
to building construction,and hereby authorize representatives of[his 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, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,tile applicmnunderstands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code.Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18,
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RP:ROOFS:
the following two reasons: All roofs shall be inspected prior many roofing material beiig installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, installed without firs[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)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
1 hereby:affirm under penalty of perjury one of the following three ALI,ROOF COVERINGS TO 13E CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I.IAZARDOUS MATFRIALSDISCLOSURE
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 read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Ilealth&Safety Code,Sections 25505,25533.and 25534. I will maintain
Section 3700 of[he Labor Code,for the performance o(the work for which this compliance with the Cupertino Municipal Code.Chapter 9.12 and the Ilealth&
F Safety Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additional]y,should I use equipment or devices which emit hazardous air
I certifythat in the performance of the work for which this permit is issued,1 shall contaminants as defined by the Ray Area Air Quality Management District 1 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 ifomia. If,after making this certificate ofexemp[ion,I Health&Safety Code,Sections 25.505,25533,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:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read tlik'application and state[hal the above information is
correct. I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a constmetion lending agency for the performance of work's
to building cons[rumion,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 l habil hies,judgments,
costs,and expenses which may accme against said City in consequence of the Lender's Address'
granting of this permit.Additionally,the applicant understands and will comply
with allnon-point source regulations per the Cupertino Municipal Code,Section ARCIUTECFS DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional