10080132 CITY OF CUPERTINO BUIL DING PERMIT
CONTRACTOR:DURA-FOAM,INC PERMIT NO: 10080132
[LDING ADDRESS: 21950 LINDY LN DATE ISSUED:08/19/2010
1185 O'BI;Ul DR
(NER'S NAME: GRACE SUN&CHI-I LANG PHONE NO:(650)327-3200
1ER'S PHONE: 4084823371
MENLO PARK,CA 94025
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT PLUMB r
ense Class Lic.# MECH r RESIDENTIAL COMMERCIAL r
ntractor Date
JOB DESI:RIPTION:SWEEP GRAVEL,CLEAN DEBRIS,SPRA Y A PPLIED FOAM
ereby affirm that I am licensed under the provisions of Chapter 9 AND
immencing with Section 7000)of Division 3 of the Business&Professions COATINGS
4e and that my license is in full force and effect.
iereby affirm under penalty of perjury one of the following two declarations:
lave 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.
lave and will maintain Worker's Compensation Insurance,as provided for by Valuation:$12095
xtion 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0
;rmit is issued.
APPLICANT CERTIFICATION
APN Num)er:35625025.00 Occupancy Type:
certify 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
n building construction,and hereby authorize representatives of this city to enter
pon the above mentioned property for inspection purposes. (We)agree to save PEPMIT EXPIRES IF WORK IS NOT STARTED
idemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
osts,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.
Ath all non-point source regulations per the Cupertino Municipal Code,Section
'•18• Issued b;,:
Date:
signature
Date
OWNER-BUILDER DECLARATION RE-ROOFS: al being
I hereby affirm that I am exempt from the Contractor's License Law for one of inslroofs:;hall be talled thout firstbtaining an inspection,I agree o remove installed.prior to ar,;-roofing materi 1 neew materialsrfor
the following two reasons:
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, Signature of Applicant: Date:
Business&Professions Code)
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 HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's
I have r
Compensation,as provided for by Section 3700 of the Labor Code,for the �:ad the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. complia ice with the Cupertino Municipal Code,Chapter 9.12 and the Health&
1 have and will maintain Worker's Compensation Insurance,as provided for by Safety(ode,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 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 maintai a compliance with the Cupertino Municipal Code,Chapter 9.12 and the
C
not employ any person in any manner so as to become subject to the Worker's Health•k Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I Owner[)r 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 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
correct.I agree to comply with all city and county ordinances and state laws relating for whi,,h 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 Lender's Address
ir^' reify and keep harmless the City of Cupertino against liabilities,judgments,
nd expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
grauLrng of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I under stand my plans shall be used as public records.
9.18.
Signature
Date Licen!ed Professional