12090154CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10400 PLUM TRrE LN
OWNER'S NAME: LOW ALFRED AND BL'TTY TRUSTEE
OWNER'S Pl IONE: 7072176022
❑ LICENSED CON"FRAC'FOR'S DECLARATION
License Class Lic.9
Contactor Dale
1 hereby affirm [hill I am licensed under the provisions of Chapter 9
(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 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.
APPLICANT" CERTI FICAT'ION
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 ordinances and state laws 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 harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
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.
CONTRACTOR: WESTSI]ORE ROOFINGI PERMIT NO: 12090154
INC
2245-A FORTUNE DR I DATE ISSUED: 09/1812012
SAN JOSE, CA 95131 PHONF-NO: (408)694-0060
BUILDING PERMIT INFO: BLDG r ELECT I_ PLUNIB (J
tYIECH r RESIDENTIAL r COMMERCIAL
,JOB DESCRIPTION: REMOVE EXISTING COMP AND INSTALL COMP ROOF
SYSTEM
25 SQ
Sq. FI Floor Area: 0 I Valuation: $9938
APN Number: 31633021.00 1 Occupancy Type:
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Date I
Issued by:
❑ OWNER -BUILDER DF-CLARAT'ION
hereby affirm that 1 am exempt from the Contractor's License Lawfor one of
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
will do the work, and the structure is not intended or offered for sale (Sce.7044,
Business & Professions Code)
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
Ihereby 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
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 ofthe Labor Cafe, for the performance of the work for which this
permit is issued.
I certify that in the performance of the work for which this permit is issued, I shall
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If, after making this certificate of exemption, I
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.
APPLICANT' CER"I'IPIC,\'PION
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to sae
indemnify and keep harn less the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of die
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.
Date:
RE -ROOFS:
All roofs shall be inspected prior to any roofing material being installed. If a roof is
installed without first obtaining an inspection, I agree to remove all new materials for
inspection.
Signature of Applicant: Dae:
ALL ROOF COVERINGS TO BE CLASS "A" OR BE rrER
IIA'LARDOUS MA'T'ERIALS DISCLOSURE
have read the hazardous materials requirements under Chapter 6.95 of the
California Ilealth S Safely' Code. Sections 25505, 25533, and 25534. 1 will maintain
compliance with the Cuperli no dlunici pal Code, Chapter 9.12 and the Health &
Safety Code, Section 25532(x) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
contaminants as defined by the Bal' Area Am Quality Management District I will
maintain Compliance with the Cuper11n0 Municipal Code, Chapter 9.12 and the
Health & Safely Code, Sections 25505.25533. and 25534.
Owner or authorized agent:
Date:
CONSrRUCITON LENDING AGENCY
1 hereby affirm that thereis a construction lending agency for the performance of work's
for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's
ARCIIITEC`I"S DECLARATION
I understand my plans shall be used as public records.
Date I Licensed Professional