12100048 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 23026 VOSS AVE CON RACFOR:BILI.HAMILTON ROOFING PERMITNO: 12100048
INC
OWNER'S NAME: TSAI VICKY T II ET AL 230 HARRISON AVE DATE ISSUED: 10/08/2012
OWNER'S PRONE: 4088872228 CAMPBELL.CA 95008 PHONE NO:(4081687-240
❑ LICENSED CONI'RACI'OR'S DEICLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Class Lie.if
AI IiCII [ RESIDENTIAL COMMERCIAL
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE AND REPLACE WITH 40YR
ommencing with Section 7000(of Division 3 of the Business S Professions CGRTAINTEED
(c
Code and that my license is in full force and effect. LANDMARK COM ,P CLASS A_8 SQ
hereby affirm under penally of perjury one of the folloo'ing rvo 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
Section 3700 of the Labor Code,for the performance of We work for which this Sq.FI Floor Area: Valuation:$14000
permit is issued.
APPLICANT CE RTI FICA'1'I ON APNNumber:34250016.00 Occupancy Type:
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
to building construction,mid hereby authorize representatives of this city to enter
uponthe above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harnless the City of Cupertino against liabilities.judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply z
with all non-point source regulations per the Cupertino Municipal Code,Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RF-ROOFS:
hereby affirm that I arm exempt from the Contractor's License Lasr for one of All roofs shall be inspected prior to any roofing material being installed,If a roof is
the following two.reasons: installed without first obtaining an inspection,I agree to remove all new materials for
1,as owner of the property,or my employees with wages as their sole compensation, inspection.
will do the work,and the structure is not intended or o0bred for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business R Professions Code). AL1,ROOF COVERINGS TO BF,CLASS"A"OR BE17ER
1 hereby affirm under penally of perjury one of the following three
declarations: IIA%xRIIOUS UA"TERLUS DISCLOSURE
have and will maintain a Certificate of Consent to selfinsure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued California Ilealth&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino lI unicipal Code.Chapter 9.12 and the Health S
Section 3700 of the Labor Code,for the performance of the work for which this Safety Code,Section 25532(a)should I store or handle hazardous material.
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 I will
I cenifv that in the performance of the work forwhich this permit is issued,I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
not employ any'person in any manner so as to become subject to the Worker's I Iealth x Safety Code,Sections 25505.25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CT•RTIFICATION CONSTRUCFION LENDING AGENCY
I certify that I have read this application and state that the above information is 1 hereby affirm that there is a construction lending agency for the performance of work's
correct.1 agree to comply with all city and county ordinances mid state Imus relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Leader's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupenino against liabilities.judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant undcrstanls and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section ARCUTFEC'I•S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional