12100035 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20819 FARGO DR CONI'RACFOR:LOS GATOS ROOFING PERMIT NO: 12100035
OWNER'S NAME: RONALD S MILLER P O BOX 1726 DA'Z'E ISSUED: 10/01(2012
OWNER'S PRONE: 4084315935 LOS GATOS,CA 95031 PI[ONE NO:(408)298-9399
❑ LICENSED CONTRACTOR'S DECLARATIONBUILDING PERMIT INFO: BLDG r ELECT 0 r
PLUMB
License Class Lic.H
111EC11 (- RESIDENTIAL(J COMMERCIAL J
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE EXISTING SHAKE ROOFING,INSTALL
(commencing with Section 7000)of Division 3 of the Business& Professions DURATION
Code and that my license is in full force and effect. MAX COMP.BY OWENS CORNING OVER OSB W/RADIANT
BARRIER 25 SQ CLASS A
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 die work for which this
permit is issued. Sq.Ft Floor Area:0 Valuation:$7885
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is APIF Number:32630130.00 Occupancy Type:
correct. I agree to comply with all city and county ordinances and state laws relating
to building construction,and herebyauthorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the 6ty 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,the applicant understands mldwill comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Cade,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
hereby affirm that I am exempt from the Contractor's License Law for one of RE-ROOFS:
the following too reasons: All roofs shall be inspected prior to any roofing material beug installed Ifa roof is
1,as owner of the properly,or my employees}with wages as their sole compensation, installed without first obtaining an inspection,1 agree to remove all new materials for
will do the work,and the struclure'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: Dale:
construct the project(Sec.7044,Business&Professions Code).
1 hereby affirm under penalty of perjury one of the following three AL1.ROOF COVERINGS TO ISE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's IIAZARDOUS DLCI'ERIA S DISCLOSURE
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 Health&Safety Code.Sections 25505,25533.and'5534. twill maintain
Sperformance of the work for which this compliance with the Cupertino Municipal Code.Chapter 9.1_and the Ilealth&
Section 3700 of the Labor Code,for the
p 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 for which this permit is issued.I shall contaminants as defined by the[lay Arca Air Quality Management District I 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 ofCalifamia. If,after making this certificate ofecemplion,I Health&Safety Code,Sections 25505,25533,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 he deemed revoked. Owner or authorized agent:
.Darr:
APPLICANT CERTIFICATION' CONST'RUCT'ION LENDING.AGENCY
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a constmction 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 properly 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 ARCHITECT'S DECLARATION
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional