10080142 CITY OF CUPERTINO BUILDING PERMIT
FBUILDINGDRESS: 11690 REGNART CANYON DR CONTRACTOR:WESTSHORE ROOFING PERMIT NO: 10080142
INC
r
2245-A FORTUNE DR DATE ISSUED:08/20/2010
_NER'S NAME: GARLIEPP JON M AND CAROL K
SAN JOSE,CA 95131 PHONE NO:(408)694-0060
U rvNER'S PHONE: 4082533769
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lic.# MECH f— RESIDENTIAL r COMMERCIAL r
Contractor Date
JOB DESCRIPTION:REMOVE EXISTING WOOD SHARE&INSTALL STONE
I hereby affirm that I am licensed under the provisions of Chapter 9 COAT?D
(commencing with Section 7000)of Division 3 of the Business&Professions STEEj,ROOF SYSTEM
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 Valuation:$34300
Section 3700 of the Labor Code,for the performance of the work for which this Sq.F,Floor Area:0
permit is issued.
APPLICANT CERTIFICATION
APN Number:36633003.00 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 ]HERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 'WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
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. Issued by: Date:
F=--nature Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
rAll oofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons: died 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, r ection.
will do the work,and the structure is not intended or offered for sale(Sec.7044, Sigi iature of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors toBETTER
—
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR
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 It►ve read the hazardous materials requirements under Chapter 6.9of the
Compensation,as provided for by Section 3700 of the Labor Code,for the
Ca iifornia Health&Safety Code,Sections 25505,25533,and 25534. 1 I will maintain
performance of the work for which this permit is issued. coi apliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I have and will maintain Worker's Compensation Insurance,as provided for by Sa ety 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 Ad ditionally,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 ms.intain 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 Hr alth&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I O,vner 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 1 tereb 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 Y
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 L!nder's Name
the above mentioned property for inspection purposes.(We)agree to save Lender's Address
nnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the DECLARATION
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S
with all non-point source regulations per the Cupertino Municipal Code,Section I understand my plans shall be used as public records.
9.18.
Signature
Date Licensed Professional