12100069 CITY OF CUPERTINO 13UILDING PERMIT
BUILDING ADDRESS: 21180 HAZELBROOK DR CONTRACTOR:PETERSEN-DEAN INC PERMIT NO: 12100069
OWNER'SNANIE: CAROLINESAAVEDRA 7980 F,N"TERPRISEDR DATE ISSUI.D: 10/10/2012
OWNER'S PHONE: 4082035936 NEWARK,CA 94560 PHONE NO:(510)194-9982
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG 1✓ ELECT r PLUNIB [,
License Chas Lie.N
N1ECF1 r RESIDENTIAL r COMMERCIAL J
Contactor Dale
1 hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REROOP:REMOVE EXISTING SHAKE INSTALL NEW
(commencing with Section 7000)of Division 3 of the Business& Professions SHEATHING AND COMP.40 SQUARES
Code and that my license is in full force and effect.
1 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
perfomtance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Sq.Ft Floor Area:0 Valuation:$14370
Section 3700 of the Labor Code,for the performance of Elie work for which this
permit is issued.
APN Number:32655025.00 OccupancyType:
AI'1'LICANI'Cl{R'1'1FICA'I"ION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmlesstheCityofCupertinoagainstliabilities.judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
casts,and expenses which mmn-v 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
❑ ON DECLARATION RE:ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law 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 conmRnsation,
will do the work,and die 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(Sce.7044,Business& Professions Code). ALL ROOF COVERINGS TO RE CLASS"A"OR BETTER
hereby affirm under penult)of perjury one of the following three
declarations: , HAZARDOUS NIATF.RIA S DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I hove read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
perfommnce of work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the perfommnce of the work for which this Additionally,should I use equipment or devices which emit hazardous air
email is issued. contaminants as defined by the Bay Area Air Quality Management District I will
F maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the perfommnce of die work far 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 Workcr's
Compensation laws ofCalifamia. If,after making this certificate ofexemption,I 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 he deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CI•.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 stale 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
granting of this permit.Additionally,the applicant underslands and will comply ARCA I"1'F:CI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18. -
Licensed Professional
Signature Date