12090191 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21897 SI'IAWUCK DR CONTRAC`T'OR:WESTERN ROOFING PERMIT NO: 12090191
SYSTEMS
OWNER'S NAME: BELL WILLIAM R AND LAWANDA I T 1328\VIIIT E,OAKS RD DA'Z'E ISSUED:09212012
OWNER'S PRONE: 4089817669 CAMPBELL,CA 95008 PHONE NO:(8311278-1837
❑ LICENSED CON'I'RAC'FOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG Ir ELECT r PLUMB rl
License Class Lic.q r r 1-'
plECll RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF COMP UNDERLAYMENT-AQUAGUARD STEEL
(commencing with Section 7000)of Division 3 of the Business S Professions ROCK
Code and that me license is in full force and effect. VILLA 23 SQ
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
pertonmince 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 Ore work for which this
permit is issued. Sq.Ft Floor Area:0 Valuation:$10265
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is ANN Number:35614006.00 Occupancy Type:
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 properly for inspection purposes. (We)agree to save
indermilyand keep harmless the City 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 and 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 by: Date:
❑ OWNER-BUILDGR DECLARATION
hereby affirm that I am exempt front 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 orthe 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 R Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business&Professions Code).
hereby affirm under penalty of perjury line of the following three ALI,ROOF COVISRINGS TO RIS CLASS"A"OR BETTER
declaralionsi
I have and will maintain a Certificate of Consent to self-insure for Worker's BAZARDOUS JIATF,RLU 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 mid will maintain Worker's Compensation Insurance,as provided for by California Ilealth S Safety Code,Sections 25505,25533,and 25534. 1 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 Ileallh S
Safety Code,Section_553_(a)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 Bay Area Air Quality Management District 1 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 California. If,after making this certificate of exemption,I Ileallh S Safely 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:
Date'
APPLICANT C ERTIFICATION CONSTRUC'PION LENDING AGENCY
I certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances and state Inns relating I hereby affirm that there is a construction lending agency for the performance of wurk'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 ARCIIITECT'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional