10080140 CITY OF CUPERTINO BUILDING PERMIT
LDING ADDRESS: 19990 HALL CT CONTRACTOR:KNIGHT ROOFING
PERMIT NO:10080140
SERVICES
42035 OSGOOD RD DATE ISSUED:08/20/2010
'TER'S NAME: FANG MARY AND JOLSON K PHONE NO:(510)438-9071
FREMONT,CA 94539
NER'S PHONE: 4084462156
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
Anse Class
Lic.# MECH r— RESIDENTIAL r COMMERCIAL
itractor Date JOB DESCRIPTION: TEAR OFF SHAKE ROOFING.INSTALL SHEATHING.
ereby affirm that I am licensed under the provisions of Chapter 9 INSTALL
mmencing with Section 7000)of Division 3 of the Business&Professions DURALITE :IGHTWEIGHT TILE ER 1647
de and that my license is in full force and effect.
ereby affirm under penalty of perjury one of the following two declarations:
ave and will maintain a certificate of consent to self-insure for Worker's
,mpensation,as provided for by Section 3700 of the Labor Code,for the
rformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for by Valuation:$17550
ction 3700 of the Labor Code,for the performance of the work for which this PAPNNum]
r Area:0
:unit is issued. Occupancy Type:
APPLICANT CERTIFICATION
er:36904017.00
:ertify that I have read this application and state that the above information is
�rrect.I agree to comply with all city and county ordinances and state laws relating
building construction,and hereby authorize representatives of this city to enter
Son the above mentioned property for inspection purposes. (We)agree to saveFPEIRR MIT EXPIRES IF WORK IS NOT STARTEidemnify and keep harmless the City of Cupertino against liabilities,judgments, W1 HIN 180 DAYS OF PERMIT ISSUANCE OR
)sts,and expenses which may accrue against said City in consequence of the
ranting of this permit. Additionally,the applicant understands and will comply 180 DAYS FROM LAST CALLED INSPECTION.
rich all non-point source regulations per the Cupertino Municipal Code,Section
Date:
18
Issued b;,:
—
' zture Date
OWNER-BUILDER DECLARATION RE-ROOFS:
] All roofs:,hall be inspected prior to any roofing material being installed.If a To
is
i hereby affirm that I am exempt from the Contractor's License Law for one of
installed�+ithout 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..
will do the work,and the structure is not intended or offered for sale(Sec.7044, Date:
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 TO BE CLASS"A"OR BETTER
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
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, erials requirements under Chapter 6.95 oft e
for the I have r-!ad the hazardous mat
Califorr is Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. complia rice 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 I store or handle hazardous material.
Section 3700 of the Labor Code,for the performance of the work for which this
Additio tally,should I use equipment or devices which emit hazardous air
permit is issued. contain Hants 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 9;Safety Code,Sections 25505,25533,and 25534.
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,I must Date: _
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I hereb+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 whi h this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating for for whi°s Name
to building construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save Lende 's Address
Minify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'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 unde stand my plans shall be used as public records.
9.18.
Date— Licen;ed Professional
Signature