12100038 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20147 LAS ONDAS WAY CONfRAC`fOR:KEVIN SULLIVAN PERMITNO: 12100038
ROOFING
OWNER'SNAMF-: JOSEL JACK G AND JUANITA G 1696 VALLEYOAKS DR DATE, ISSUED: 10/612012
OWNEMS I'IONF,: 4085989798 GILROY.CA 95020 PHONE NO:(408)842-1057
❑ LICENSED CON`fRAC`FOR'S DECLARATION BUILDING PERMIT INFO: BLDG I— ELECT❑ PLUMB
License Class Lic.q.
MECII (- RESIDENTIAL J COMMERCIAL 0
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:TEAR OFF EXTISTING ROOF. INSTALL 7/1614 SQ CLASS
(commencing Leith Section 7000)of Division 3 of the Business&Professions A
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following mo 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 Sq.Ft Fluor Area:0 Valuation:$11400
Section 3700 of the Labor Code,for the performance of die work for which this
permit is issued.
APN Number 36931001.00 Occupancy"Type:
APPLICANTCERTI FICATIO,N
I cenify that I have read this application and state that the above infomhation is
correct.I agree to comply with all city and county ordinances:rad state laws relating
to building construction,and hereby authorize representatives of this city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (Ilse)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN Igo DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accme against said City in consequence of the I gp PAYS FROM LAST CALLED INSPECTION.
gmnting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date.
Signature Dale
❑ OWNER-BUILDER DECLARATION RF:ROOFS:
All roof's shall be inspected prior to any roofing material beiig installed.If a roof is
hereby affirm that I am exempt from the Conlractnr's License Law for one of installed without first obtaining an inspection,.I agree to remove all new materials for
the following two reasons: inspection.
I,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant: Date:
Business&Professions Code)
I,as owner of properly,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the folliming three
declarations: IIA--/,ARDOUS MATERIAIS DNCLOSURE
I have and will maintain a Ceni Ocate of Consent to self insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,is provided for by Section 3700 of Labor Code,for the California Ilealth&Safety Code.Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance frith the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insur:mcc,to provided for by Safety Code,Section 25532(x)should I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District 1 mill
maintain compliance with the Cupertino Municipal Code,Chapter 9.1_and the
I certify that in the performance of the Work fonvhich this permit is issued,I shall Dcallh&Sudety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this pemhit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
ArrLICAN7'Cf,R'1'IEIC.\TION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application mid state that the above information is for which this permit is issued(Sec.3097,Civ C.)
cored. I agree to comply with all city and county ordinances Iced state lass relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned properly for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against liabilities.judgments,
costs,and expenses which may.accrue against said City in consequence of the
granting of pemmit.Additionally,the applicant understands and will comply .\RCIII"fECI"S I1F:CLARA'I'ION
with all non-point source regulations per the Cupertino Municipal Code,Section I undmarind my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date