12110032 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7619 ERIN WAY CONTRACTOR:LOS GATOS ROOFING PERMIT NO: 12110032
OWNER'S NAME: CI'IIN WAYNE F P O BOX 1726 DA'Z'E ISSUED: 11/062012
OWNER'S PHONE: 4082577181 LOS GATOS.CA 95031 PHONE NO:(408)298-9399
❑ LICENSED CON-1'RACLOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT IJ PLUMB r
License Class Lie.q
i\IECI1 r RESIDENTIAL r7 l COMMERCIAL C�
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING COMP.ROOFING. INSTALL 24 SQ.
(commencing with Section 7000)of Division 3 of the Business S Professions LANDMARK TL COMP.OVER EXISTING PLYWOOD.
Code and that my license is in full force and effect.
1 hereby affirm under penalty of perjury one of the following byo 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:$6019
Section 3700 of the Labor Code,for the performance of the work for which(his
permit is issued.
\I'N Number:35920018.00 Orcupmmcy'I'}pe:
API'LICAN"I'CER'1'IFIC,\TION
I certify that 1 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,and hereby authorize representatives of this city,to enter PERMIT EXPIRES IF WORK ISNOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,[tic applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARA'T'ION Rh:ROOFS:
All roofs shall be inspected prior to any reading material beug installed.If a roof is
hereby affirm that Into exempt from the Contractor's License Lawfor one of installed without first obtaining at inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,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 the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS TO RE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS\MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation;as provided for by Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505.25533,and 25534. 1 will maintain
performance of the work for which this permit is issued compliance with the Cupertino Municipal Code.Chapter 9.12 and the I Iealth&
I have and will maintain Worker's Compensation Insurance,as provided for by Safely Code.Section 25532(a)should I store or handle hazardous material.
Section 3700 ofthe Labor Code,for the performance of the work for which this Additiomdly, should 1 use equipment or devices which emit hazardous air
condi minams as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall I Iealth&Safety 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 certifhcae of exemption,1 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 permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT'CERTI FICATION I hereby affirm that there is a construction lending agency for the performance of ssork's
I certify that I have read this application and state that the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Lender's Name
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupertino against Iiabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this pemmil.Additionally,the applicant understands and will comply ARCIIITECI"S DECLARATION
with all non-pointsource regulations per the Cupertino Municipal Code,Section 1 undersu and my plans shall be used m¢public records.
9.18.
Licensed Professional
Signature Date