12100115 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18872 LOREE AVE CONFRACfDR:ALL SEASONS PERMITNO: 12100115
ROOFING 8 SOLAR
ONVNhR'S NAM F: Y I M SANG J AND SONG S 1720 SMI. I-I AVE DATE ISSUED: 10/15/2012
OWNER'S PDONE: 4085292598 SAN JOSE,CA 95112 NIONE,NO:(408)971-4455
❑ LICP:NSED CON I'RACI'OR'S DECLARATION r r r
BUILDING 1'ERNI
ERIINFO: SLUG ELECT PLUMB
License Class Lie.# r r r
NIECII RESIDENT[Al. CONINIERCIAI,
Contractor Date .106 DESCRIPTION:TEAR 017171 LAYER Op EXISTING AND REPLACING OSB
DECKING.GASTIMBERLINE CRARCROL
hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Di%ision 3 of the Business& Professions
Cade and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will mainmin 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 whichthis permit is issued. Sq.Ft Flour Area: Valuation:$8460
1 have and will mainmin Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for die performance of die work for which this
Ali\\umber:3750016.00 Occupancy'I'ypr.
permit i5 Issued.
Ai'PI;ICAN''I'CER'FIFICA'I'ION
I certify that I have read this application and state that the above inftimmion is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.l agree to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant unders arids:md will comply Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code.Section
9.18.
RF:ROOFS:
Signature Date All roofs shall be inspected prior to my roofing material being installed.I f a roof is
installed without First obtaining an inspection,I agree to remove all new materials for
inspection.
❑ OWNER-RIIILDI?R DECLARATION'
Signature of Applicant: Date:
herrhy affirm that I am evempl from the Contranor's Licenxc Law for one of
the following bro reasons: ALL ROOF COVERINGS TO BE CLASS"A"OR BF.'I-1'F.R
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work,Jud the structure is not intended or offered for sale(Sec.7044,
Business K Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to IIA%ARDOIIS MATERIALS DISCLOSUREi
construct the project(Sec.7044,Business S Professions Code). I have read the hazardous materials requirements under Chapter 6.95 of the
California IIealth S Safety Code,Sections 25505,25533,and 25534. 1 will
hereby affirm under penaltyof perjuy one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
declarations: Ilealth X Safety Code,Section 25532(a)should I store or handle hazardous
I have and will mainmin a Certi Ficate of Consent to self-insure for Worker's material. Additionally,should I use equipment or devices which emit hazardous
Compensation,as provided for by Section 3700 of die Labor Code,for the air contaminants as defined by the Bay Arca Air Quality Nlanagement District
performance of the work for which this permit is issued. will maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and
I have and will mainmin Worker's Compensation Insurance,as provided for by the Ilealth S Safety Code.Sections 25505.25533.and 25534.
Section 3700 of the labor Code,for the performance of die work for which this
Owner or authorized agent: Date:
permit is issued.
I certify thin in the performance of die work for which this permit is issued,I shall
not employ any person many manner so as to become subject to the Worker's
Compensation laws of Col ifamo. If,ager making Ohis certif icate of exenhption,l CONS'fRt1C1'ION LENDING AGENCY
became subject to the Worker's Compensation provisions of the Labor Code,I must I hereby ammo that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked. work's for which this permit is issued(Sec.3097,Civ C.)
Lender's Name
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and some that the above in(mrution 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
indemnify and keep harmless the City of Cupertino against liabilities,judgements, ARCHITECTS DECLARATION
costs,and expenses which may accrue against said Cit'in consequence of the I understand my plans shall be used as public records.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point Source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18,
Signature Date