09100045 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20891 MC CLELLAN RD CONTRACTOR:CUSTOM ROOF PERMIT NO:09100045
CRAFTERS
'ER's NAME: SHAYNE STUBBS 2997 BUTLER LN DATE ISSUED: 10.'07/2009
OWNER'S PHONE: 6502732271 VALLEY SPRINGS,CA 95252 PHONE NO:(209)45 5-1,34
I/ LICENSED CONTRACTOR'S DECLARATION r r
BUILDING PERMIT INFO: aline ELECT PLUMB
License Class F
MECH RESIDENTIAL COMMERCIAL
Contractor ' +.)1-14 0M 111f Date l O_L_J
� .lOs DESCRIPTION: REMOVE SHAKE ROOF PAR-PIAL RE-
I hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000)of Divisions of the Business&Professions SHEATHING
Code and that my license is in full force and effect. 36 SQ, METAL.ROOF 24 GAUGE
1 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 pennit is issued. Sq.Ft Floor Area:0 Valuation:$25000
1 have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of Ste work for which this APN Number:35913083.00 Occupancy Type:
permit is issued.
APPLICANT CERTIFICATION
I certify that I have read this application anct state that the above information is PERMIT EXPIRES IF WORK IS NOT STARTED
correct.I agr=e to comply with all city and county ordinances and state laws relating WITHIN 180 DAYS OF PERMIT ISSUANCE OR
to building consttuction.and'hereby authorize representatives of this city to enter
upon the above mere,toned property for inspection purposes. (We)agree to save 180 DAYS FROM LAST CALLED INSPECTION.
indemnify am6 ke.,p harmless the City of Cupertino against liabilities,judgments, I
costs,and expeps,-s which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Issued by: _ Date:
with all non-point soun.e regulations per he Cupertino Municipal Code,Section
RE-ROOFS.
Kate 10 k-0 11 All roofs shall be inspected prior to any roofing material being installed h`a roof is
`_ I
installed without fest obtaining an inspectiou,I agree to remove all new-nateriais fur I
inspection.
❑ OWNER-BUILD DECLAKUI i ION I
Signature of Applicant: Date: _
1 herebv affirm that 1 ant exempt from the Contractor's License Law for one of
the following two reasons: ALL ROOF COVFRINCS'i O BE CLASS"A"OR BEYI ER
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, I
I
Business&Professions Code) I
1,as owner of ihe property,am exclusively contracting with licensed contractors to HAZARDOUS MATERIALS DISCLOSURE li
construct the project(Sec.7044,Business&Professions Code). i have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will
I hereby affirm under penalty of perjury one of the following three maintain compliance with the Cupertino Municipal Code,Chapter 9.1.2 and the
declarations: Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
I have and will maintain a Certificate of Consent to self-insure for Worker's material. Additionally,should 1 use equipment or devices which limit hazardous
Compensation,as provided for by Section 3700 of the Labor Code,for the air contaminants as defined by the Bay Area Air Quality Management District
performance of the work for which this permit is issued. will maintain compliance wish the Cupertino Municipal Code,Chapter 9.12 anti
i have and wiil maintain Worker's Compensation Insurance,as provided for by the Health&Safety Code,Sections 25505,25533,and 25534.
Section 3700 of the Labor Code,for the performance of the work for which this
Owner or authorized agent:_ _ Date:—
ne.rntrt is issued.
I certify that in the,performance of the work for which this permit is issued,I shall I
not employ any person in any manner so as to become subj9Qt to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I CONST RUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code,I must I hereby affirm that there is a construction lending agency for the perlo:manee of
forthwith comply with seen provisions or this permit shall be deemed revoked. work's for which this pennit is issued(Sec.3097,Civ C 1
Lender's Name--------- - -- ------ ---
APPLICANT CERTIFICATION Lender's Address
I certify that I have read this application and state that the above information rs
correct. I agree to comply with ail city and county ordinances and state laws relating
lding construction,and hereby authorize representatives of this city to enter
t, the above mentioned property for inspection purposes.(We)agree to save
i indemnify and keep barmless the City of Cupertino against iiabilities,judgments, ARCHITECT'S DECLARATION t
coats,and expenses which may accrue against said City in consequence of the I un&rstand my plans shall be used as public r„cords.
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature___ —_— Date____
V/