12100096 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 22157CLEARCREEKCT CONTRACTOR:LOS GATOS ROOFING PERM IT NO: 12100096
OWNER'SNAME: LAW MARK A AND LATER MARY L P O BOX 1726 DA'Z'E ISSUED: 1011112012
OWNER'S PIIONE: 4088916327 LOS GATOS.CA 95031 PHONE NO:(408)298-9399
❑ I-ICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG I. ELECT r PLUMB CJ
License Class Lic.H D1ECI1 RESIDENTIAL r_ r
COMMERCIAL r
Contractor Date
hereby affirm that I am licensed uAND
tinder the provisions of Chapter 9 DESCRIPTION: REMOVE EXISTING SHAKE ROOFING. INSTALL OSB
(commencing with Section 7000)of Division 3 of the Business 8 Professions AND
Code and that my license is in full force and effect. '-3 SQ.PRESIDENTIAL COMP.BY CERTAINTEED. 4:12
PITCH
hereby affirm under penalty of perjury one of the following mo 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 die work for which this
permit is issued. Sq.Ft Floor Area:0 Valuation:$9421
APPLICANT'CER'I'IFICA'1•ION
I certify that 1 have read this application and state that the above information is APN Number:32618018.00 Occupancy Type:
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 properly 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 ofthe
granting of this permit. Additionally,the applicant understands and will comply WITHIN ISI) 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.
Date Issued fly:y: Dale:
❑ OWNER-BUILDER DECLARATION
I hereby afirm that 1 am,esempt 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
1,as owner of the property,or my employeeslvith wages us;their sole compensation, installed without first obtaining an inspection,1 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).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirnn under penally of perjury one of the failuwing three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IIAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the stork for which this permit is issued. I hove read the haznrdnus materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California health&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
compliance with the Cupertino Municipal Cade.Chapter 9.12 and.the Ilcalth&
Section 3700 of tire Labor Code,for the performance of the work for which this Safety Code,Section 25532(x)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 the work forwhich this permit is issued,I shall contaminants as defined by the Bay Area Air QualityManagement 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 California. If,after making this cenilicate ofexemplion,I Ilcalth&Safety Code.Sections 25505,25533,and 25534.
become subject to the Worker's Compensraion provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked Owner or authorized agent:
.Dale
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I hereby acorn that there is a construction lending agency for the performance of work'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 ARCI IITECI"S DECLARATION
9.18.
I understand my plans shall be used as public records.
SignatureDate
Licensed Professional