12090136 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 811511YANNISPORT DR CONTRAC`T'OR:WESTSHORE ROOFING PERMIT'NO: 12090136
INC
OWNER'SNAME: MITC1]ELL JERALDINE K 2245-A FORTUNE DR DATE ISSUED:09/14/2012
OWNER'S PHONE: 4084897926 SAN JOSE.CA 95131 PHONE NO:(408)694-0060
❑ LICENSED CON'TRACTOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lic.q
N1ECH — RESIDENTIAL _I COMMERCIAL C.
Contractor Date
1 hereby offirm that I am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE EXISTING WOOD SHAKE AND INSTALL COMP
(commencing with Section 7000)of Division 3 of the Business& Professions OV17R
Code and that my license is in full force and effect. NEW OSB 27 SQFT
1 hereby affirm tinder 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 Elie work for which this Sq.Fl Floor Area:0 Valuation:$15072
permit is issued.
APPLIC N'r CERT'I FI CATION APN Number:35611015.00 Occupancy Type:
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 save PERMIT EXPIRES IF WORK IS NOT STARTED
militarily,and keep harmless the City of Cupertino against liabilities,judgments,
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 applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER-RIALDER DECLARATION
RE-ROOFS:
hereby affirm that I am exempt from the Contractor's License Law 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(Sce.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). AL1,ROOF COVERINGSTO BE CLASS"A"OR RETFER
I hereby affirm under penalty of perjury one critic following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS NIAT'ERLU S DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the I hove read the hazardous materials requirements under Chapter 6.95 of the
perfommnce of the work for which(his permit is issued. California Ilculth&Safety Code,Sections 25505,25533,and 25.534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the lleallh&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code.Seclimr25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bay Aren Air Quality Management District 1 will
I certify that in the performance of die work forwhich this permit is issued,I shall maintain compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Health&Safety Code,Sections 25505,25533,and 25534.
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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked Date:
,%I'1'LICA,N1'CF,R'I'IFIC PION CONSTRUCTION LENIHNG AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of mark's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ Q
to building construction,and hereby authorize representatives of this city to enter Leader'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 in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
all non-point source regulations per the Cupertino Municipal Cade,Section
9.18. 1 understand my plans shall.be used as public records.
Signature Date Licensed Professional