09080017 t CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10415 IMPERIAL AVE C:)NTRACTOR:BAY 101 ROOFING PERMIT NO:09080017
OWNER'S NAME: PATEL SAMPADA
P,)BOX 925 DATE ISSUED:08/04/2009
ALVISO,CA 95002 PHONE NO:(408)957-0531
ER'S PHONE: 4089570531
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class e—'-3 Lic.# �O MECH RESIDENTIAL COMMERCIAL
Contractor/Sf/Y� r/4' &0�Date - 0
JOB DESCRIPTION:RE-ROOF TEAR OFF WOOD SHAKES INISTALL
1 hereby affirm that I am licensed under the provisions of Chapter 9 30#FELT
(commencing with Section 7000)of Division 3 of the Business&Professions F,EFORE OSB ADD COMP 40 YEAR CLASS A 37SQ
Code and that my license is in full force and effect.
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 y,Ft Floor Area: Valuation:$15000
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. kPN Number:35719100.00 Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
correct.1 agree tocomply with all city and county ordinances and state laws relating PERMIT EXPIRES IF WORK IS NOT STARTED
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save WITHIN 180 DAYS OF PERMIT ISSUANCE OR
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue a nst said City in consequence of the 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Addition Ily, e ap licant understands and will comply
with all non-point source ula on er the Cupertino Municipal Code,Section Date:
9.18. Issued by
Signature Date
G 4RE-R
OWNER-BUILDER DECLARATION
All roofs shall be inspected prior to anvial being installed.If a roof is
1 hereby affirm that 1 am exempt from the Contractor's License Law for one of installed without first obtainin4anin 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, Date: i
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
Certificate of Consent to self-insure for Worker's I have read the hazardous materials requirements under Chapter 6.95 o the
I have and will maintain a Certifi
Compensation,as provided for Section 3700 of the Labor Code,for the California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by Safety Code,Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this contaminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,l shall Health&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 certificate of exemption,I Owner or autho�d t• Date:C/ / 9
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work'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
inr' nify and keep harmless the City of Cupertino against liabilities,judgments,
a :id expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
graTnrng of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section 1 understand my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date