11090090 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10301 S BLANEY AVE CONTRACTOR:WESTSHORE ROOFING PERMIT NO: 11090090
INC
OWNER'S NAME: HAGGARD AMBROSE L AND SABINA A 2245-A FORTUNE DR DATE ISSUED:09/13/2011
!ER'S PHONE: 4158061451 SAN JOSE,CA 95131 PHONE NO:(408)694-0060
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG� ELECT� PLUMB�
License Class Lic.#
MECH RESIDENTIAL COMMERCIAL I—
Contractor Date
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE EXISTING WOOD SHAKE AND INSTALL COMP
(commencing with Section 7000)of Division 3 of the Business&Professions ROOF
Code and that my license is in full force and effect. SYSTEM OVER NEW OSB SHEATHING
I hereby affirm under penalty of perjury one of the following two 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 the work for which this Sq.Ft Floor Area:0 Valuation:$9105
permit is issued.
APPLICANT CERTIFICATION APN Number:36932013.00 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,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless 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 180 DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18.
Signature Date Issued by: Date:
OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law 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
I,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 offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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 Health&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 Municipal Code,Chapter 9.12 and the Health&
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 certify that in the performance of the work for which 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 Health&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,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
it' anify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
g,_Iang of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional
CITY OF CUPERTINO BUILDING PERM
BI'ILDING ADDRESS: 902 BLAZIN6W00D AVE CONTRACTOR:ROCHA'S COMPANY PERMITNO: 11050070
OWNER'S NA:N1E: BALAKRISHNAN SATISI-I 2191 MONTICELLO AVE DATE ISSUED:07/08/2011
:R'S PHONE: 4083092954 SAN,LOSE,CA 95125 PHONE NO:(408)593-7405
❑ LICENSED CONTRACTOR'S DECLARATION
BUILDING PERMIT INFO: BLDG ELECT ' PLUMB
I.icense Class Z�_ Lic.N
-- MECH RESIDENTIAL COMMERCIAL
contractor _y _Dale �__ _�__�_
t ,JOB DESCRIPTION: ADD 1,606 SQ FT TO LIVING,DINING,FOYER.
I hereby affirm that 1 am licensed under the provisions of Chapter I MASTERUTTE,PATIO AND GARAGE,REMODEL. 1,257 SQ FT
(commencing with Section 7000)of Division 3 of the Business& Professions THROUGH OUT BEDROOMS,KITCHEN AND BATHS
Code and that n» license is in full force and effect.
8/2/201 1-Df::FFERED#I-DEFERRED TRUSSES-9/13/2011 REV#I ISS'D
I hereby affirm under penalty of perjury one of the following two 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 Hill maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area: Valuation:$180000
permit is issued
APPLICANT CERTIFICATION APN Number:36917016.00 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,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes (We)agree to save PERMIT EXPIRES IF WORK IS NOT STARTED
mdcnuiitN and keep harmless the City of Cupertino against liabilities,judgments,
cots,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
-ranting of this permit. Add nilly,the applicant un tands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
tth all non-point source r ulations per the CyffN o unicipal Code,Section
Q 18 _ Cr
Issued by: - -.-: ? ___-— Date: /2
Signature__ Date
OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that 1 am exempt from the Contractor's License Law,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 offered for sale(Sec.7044,
13us111ess& professions Code) Signature of Applicant:___- Date.
L a>S owner of the property,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 following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 1 have read the hazardous materials requirements under Chapter 6.95 of the
perfnrmance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
1 have and w ill maintain Worker's Compensation Insurance,as provided for by compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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 1 use equipment or devices which emit hazardous air
permit is issued contaminants as defined Ir he Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued,I shall maintain complia nee
W.
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&Safety Co ,Sectio 25505 25 3,and 25534.
f
Compensation laws oCalifornia. If,after making this certificate of exemption,1
become subject to the Worker's Compensation provisions of the Labor Code,I must O r o ze ge
torthw nh comply with such provisions or this permit shall be deemed revoked. Date:
✓CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
1 certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct. I agree to comply with all city and county ordinances and state laws relating for which this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lender's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, Lender's Address
and expenses which may accrue against said City in consequence of the
;ng of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
-n all non-point source regulations per the Cupertino Municipal Code,Section
I I understand my plans shall be used as public records.
Signature Date Licensed Professional