12100095 CITY OF CUPERTINO i3UILDiNG PERMIT
BUILDING ADDRESS: 10238 RICIIWOOD DR CON TRACTOR:WESTERN ROOFING PERMITNO: 12100095
SYSTEMS
OWNER'S NANIF: FAUCETTJOHN WAND DFLORES A 1328 WIITIT OARS RD DATE ISSUED: 10/1112012
ONVNFR'S PHONE: 4082573394 CANIPBELL,CA 95008 PHONE NO:(83D2784837
❑ I.ICF,NSED CO\FRAC'FOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT r PLUMB r.
License Class Lia k
blECll [ RESIDENTIAL❑ COMMERCIAL'
Contractor Date
I hereby affirm thnt I am licensed under the provisions of Cha pier .1013 DESCRIPTION:TEAROFF WOOD SHARE AND INSTALL METAL SHAKE
(commencing w'ilh See Iian 7000)of Division 3 of the Business& Professions PER
Code and that my license is in full force and effect. ER3098
29 SQ
1 hereby aRrm 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 die 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 Sin work for which this
permit is issued. Sq. Ft Floor Area:0 valualion:$16500
APPLICANI'CERTIFICATION
I cenify that 1 have read this application and state that the above information is APN Number:36908026.00 Occupancy Type:
cored.I agree to comply with all city and county ordinances and stale 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
indemnify and keep harmless the City ofCupertino against liabilities,judgments, PERMIT EMPIRES IF WORK IS NOT STARTED
costs,and expenses which may accme against said City in consequence of the
granting of this permit. Additionally,the applicant understands mid will comply WITHIN 180 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.
Signature Date Issued bv: Date:
❑ OWNER-RUILDF,R DECLARATION
hereby affirm that I am exempt 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 employees With wages as their sole compensation, installed without first obtaining an inspection,I 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)
I,as owner of the property,son exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(See.7044,Business&Professions Code).
hereby affirm under penalty of perjury one of the following three ALI,ROOF COVERINGS TO BE CLASS"A"OR BETTER
declarations-
I have and will maintain a Ceni Ocate of Consent to self-insure for Worker's IIA%ARDO11S NIATER1A1S DISCLOSURE
Compensation,as provided for by Section 3700 of die 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 Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilealth&
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
1 certify that in the performance of the work forwhich this permit is issued,I shall contaminants as defined by the Bay Area 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 of Cal ifomia. If,alter making this certificate of exemption,I Ilealth&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 be deemed revoked. Owner or authorized agent:
Dole:
nrrt.IC\Nr CIiR'fIPIC\PION CONSTRUCTION[,ENDING 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 ordimmces mid state Imus relating I hereby affmi 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 ARCHITECT'S DECLARATION
9.18,
I understand my plans shall be used as public records.
Signature Date
Licensed Professional