12100038 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20147 LAS ONDAS WAY CONTRAC'T'OR:KEVIN SULLIVAN PF,RNIFF NO: 12100038
ROOFING
OWNER'S NAME: JOSEL JACK G AND JUANITA G 1696 VALLEY OAKS DR DATE ISSUF,D: 10/042012
OWNER'S 1.11ONE: 4085989798 GILROY,CA.95020 PHONE NO:(408)842-1057
❑ LICENSED CON'TRACTOR'S DIiCLA RATION BUILDING PERMIT INFO: BLDG [ ELECT I_ PLUMB IJ
License Class LIC.t!
MEC11 r RESIDENTIAL rl COMMERCIAL r
Contractor Date
hereby'affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF E\TISTING ROOF. INSTALL 7/1624 SQ CLASS
(commencing with Section 7000)of Division 3 of the Business&Professions A
Code and that my license is in full force and effect.
1 hereby affirm under penally 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 Sq.Ft Floor Area:0 Valuation:$11400
permit is issued.
APPLICANT CERTIFICATION APNNumber:36931001.00 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
indemnify and keep harmless the City of Cupertino against l tabililies,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 applicamunderstands 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
❑ OWNFR-BIIILDF.R DECLARATION
RE-ROOFS:
hereby affirm(hat 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,1 agree to remove all new materials for
1,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(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). AL1,ROOF COVF,RINGS TO BE CLASS"A"OR BETTER
1 hereby 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 II,A7.,\RDOUS MA'fERLUS DISCLOSURE
Compensation,as provided for by Section 3700 of Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I he and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 2.5532(x)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 Boy Area Air Quality Management District 1 will
I certify that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's Ilealth&Safety Code.Sections 25505.25533,and 25534.
Compensation laws of California. If,after making this cenificate 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:
CONSfRUCfION LENDING AGENCY
APPLICANT CERTIFICATION
1 certify that 1 have read this applicationand state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
coffee(. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender'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 comph ,ARCIII'I'ECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section -
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional