13020147 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7570 SQUIREWOOD WAY CONTRACTOR:WESTSHORE ROOFING PERMIT NO: 13020147
INC
2245-A FORTUNE DR DATE ISSUED:02272013
OWNER'S NAME: CHARLES&TSAI PEI CHUN CHU PHONE No:(aoa)69a-0060
SAN JOSE,CA 95131
OW'NER'S PHONE: 4083343705
DECLARATION
0 LICENSED CONTRACTOR'S N NFO: BLDG r ELECT F PLUMB
BUILDING PERMIT Ir
F
r r
License Class Lic.# MECH RESIDENTIAL COMMERCIAL
Contractor
Date JOB DESCRIPTION: REMOVE EXISTING COMP ROOF AND INSTALL COMP
I hereby affirm that I am licensed under the provisions of Chapter 9 ROOF
(commencing with Section 7000)of Division 3 of the Business&Professions
SYSTEM-20 SQ
Code and that my license is in full force and effect.
I hereby affirm under penalty of perjury one of the following two declarations:
1 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.
1 have and will maintain Worker's Compensation Insurance,as provided for by Valuation:$9866
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0
permit is issued. Occupancy Type:
APPLICANT CERTIFICATION APN Number:362-26-036
ove
formation is
I certify that I have ready with all chinn and state that the at
and county Ordinances andmstate.laws relating
correct.I agree tr comply y
to building construction,and hereby authorize representatives of(We)
city to enter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabiliues,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,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Date:
9.18. Issued by:
Signature Date
OWNER-BUILDER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If roof is
for one of
I hereby affirm that 1 am exempt from the Contractor's License Law installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons:
1,as owner of the property,or my employees with wages as their sole compensation, inspection. Uato.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signature of Applicant:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS'fO BE CLASS"A"OR BETTER
1 hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURF,
declarations:
1 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 0 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 Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should 1 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 Arca Air Quality Management District I will
Safety 25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,)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 Health&Sate Code,Sections 25505,
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,1 must Date:
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LF,NDING AGENCY
APPLICANT CERTIFICATION I herebyaffirm that there is a construction lending agency for the performance of work's I
1 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 bender'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 pRCHITFCT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Date Licensed Professional
Signature