10060206 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10714 LA RODA DR CONTRA TOR:LINDY ROOFING CO INC PERMIT NO: 10060206
476 W TAYLOR ST DATE ISSUED:06/30/2010
OWNER'S NAME: VEUM HARLAND V AND RUTH M TRUS
PHONE NO:(408)286-9990
SAN JOSE,CA 95110
.QER'S PHONE: 4082577313
] LICENSED CNTRACTOR'S DECLARATION BUILDI14G PERMIT INFO: BLDG ELECT PLUMB
O
.icense Class Lic.# MECH[- RESIDENTIAL COMMERCIAL
ontractor Date
JOB DESCRIPTION: REMOVING THE EXISTING 2 LAYER WOOD SH
AKE
f hereby affirm that I am licensed under the provisions of Chapter 9 ROOFS A 1D
'commencing with Section 7000)of Division 3 of the Business&Professions INSTALL NG 1/2
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:$15000
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft FI 3or Area:0
permit is issued.
APPLICANT CERTIFICATION
APN No ober:36934042.00 Occupancy Type:
I certify that 1 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 PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the W[THIN 180 DAYS OF PERMIT ISSUANCE
OR
granting of this permit. Additionally,the applicant understands and will comply 181) DAYS FROM LAST CALLED INSPECTION.
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of nltrool shall
lbinecedprior toanyr ng material
to being
installed.
roof is
the following two reasons: hfirst obtainingrt insptionagree all materials r
1,as owner of the property,or my employees with wages as their sole compensation, inspecti an.
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 read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the
Califo-ria Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compl ance 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 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 maint tin 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&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 certify that I have read this application and state that the above in is I here)y affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state laws relating for w1 rich this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lend;r's Name
unon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
inify and keep harmless the City of Cupertino against liabilities,judgments,
and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCHITECT'S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section I and,-rstand my plans shall be used as public records.
9.18.
Signature
Date Licensed Professional