12090194 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7517 ORANGE BLOSSOM DR CONTRACTOR:WESTSI]ORE ROOFING PF.RMITNO: 12090194
INC
OWNER'S NAME: PROUT GERALD R AND BONNIE 1 2245-A FOR'T'UNE DR DATE ISSUED:09212012
OWNER'S PUONE: 4082536016 SAN JOSE.CA 95131 PRONE NO:(408)694-0060
❑ LICENSED CO IRA(TOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT IJ PLUMB IJ
License Class Lic.b
M ECH r RESIDENTIAL Cl COMMERCIAL(_�
Contractor Date
1 herebyaffirm(hat I am licensed under the provisions of Chapter 9 3013 DESCRIPTION: REMOVE EXISTING WOOD SIIAKE AND INSTALL COhIP
(commencing with Section 7000)of Dh ision 3 of the Business S Professions OVER
Code and that my license is in full force and effect. 7116
26 SO
I hereby affirm under penalty of perj on.one of the folio,ing leo dechurat ions:
I have and will maintain a cenificare of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of Labor Code,for the
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,is provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area;0 Valuation:$12011
APPLICAMI'CERTIFICATION
I certify that I have read this application and slate that the above information is APN Number:36611049.00 Occupancy Type:
correct. I agree to comply with all city and count)'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 stave
indemnify and keep harmlesstheCityofCupertinoagainstliabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
gracing of this permit. Additionally,the applicant understandsand will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regula(ims per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
❑ O\VNF.R-RUILDF.R DECLARATION
I 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 my 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(Sea7044, inspection.
Business R Professions Code)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business R Professions Code).
hereby affirm under penalty of perjury one of the following three ALL ROOT'COVERINGS TO BE CLASS"A"OR BETTER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's TIA'LARDOUS MA'fERIAI 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 Ilealth S Safely Code,Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for theerformanee of the work for which this compliance with the Cuperdim Municipal Code,Chapter 9.12 and the Ilenith S
P Safety Code.Section 25532(a)should )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 for which this permit is issued.I shall contaminants as defined by the Ray 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 Imus of California. If,after making this certificate of exemption,I Ilenith A 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:
Date'
APPLICANT CERTIFICATION CONSTRUCT-ION LENDING 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 ordinances and state laws relating I hereby affirm 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 hammless 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 regulation per the Cupertino Municipal Code,Section ARCI I ITE.Cf'S DECLARATION
9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional