10010122 TIN O BUILDING PERMIT O:l 0010122
WF
CITY OF CUPER STERN ROOFING PERMIT N
CONTRACTOR:
BUIL
DING ADDRESS. 10619 FARALLONE DR SYSTEMS DATE ISSUED:01/22/201
1328 WHITE OAKS
PHONE NO:(831)27$-1837
L BR'S NAME: MTTCHELL RUBY B CAMPBELL,CA 95008
: 4089961428 � ELECT� PLUMB
OWNERS PHONE IT INFO: BLDG
TOR'S DECLARATION BUILDING PERM rMMERCIAL
NTRA
13 LICENSED COC MECH r RESIDENTIAL CO
#
License Class Lic. SCRIPTION:'TEAROFF WOOD SH,KE,FILL SHEETING A
Date JOB DE
Contractor provisions of Chapter 9 NEEDED.40LBS METAL SHAKE PER EIt5626
I hereby affirm that I am licensed under the p FELT,INSTALL ME
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license id effect.
s in full force an
affirm under penalty of perjury one of the following two declarations:
I hereby
maintain a certificate of consent to self-insure fo
Code,for the
I horkerls
ave and will m provided for by Section 3700 of the Labor
Compensation,asp permit is issued. Valuation:$16500
performance of the work for which this p provided for by
Compensation Insurance, Ft Floor Area:0
I have and will maintain Worker's
for the pefformance of the work for which this Sq. anc Type:
Section 3700 of the Labor C occupancy Yp
permit is issued. N APN Number:36939038.00
APPLICANT CERTIFICATION
read this application and state that the Ces and stabove te laws relating STARTED
I certify that atiOn is
I have and county ordinances to enter S IF WORK IS NOT
correct.I agree to comply with all city PERMIT EXPIRE CE OR
traction,and hereby authorize representatives of this to save PERMIT ISSUANCE
to building cons for inspection purposes. (W ) gr
against liabilities,judgments, THIN 180 DAYS OF
upon the above mentioned propertyiTy of Cupertino of the ST CALLED INSPECTION.
and keep harmless against said City in consequenceFROM LA
indemnify accrue ag
d expenses which may 180 DAYS F
costs,anp Additionally,the applicant understands and will comply
granting of this permit. Cupertino Municipal Code,Section Date:
oint source regulations per the Cup
with all non-p Issued by:
9.18. Date
nature
RE-ROOFS: installed.If a roof is
TION inspected prior to any roofing material being
OWNER-BUILDER DECLARATION in an inspection,I agree to remove all new materials for
n he Contractor's License Law for one of All roofs shall be insp
affirm that I am exempt from t installed without first obtaining
I hereby ensation, inspection.
the following two reasons: employees with wages as their sole comp Date:
1,as owner of the property,or my Applicant'
d the structure is not intended or offered for sale(Sec.70 � Signature of
will do the work,anOR BETTER
Business&ProfessionsCode)
exclusively contracting with licensed contractors to
ALL ROOF COVERINGS TO BE CLASS
1,as owner of the property,
nstruct the project(Sec.7044,Business&Professions Code). DISCLOSURE
co three
HAZARDOUS MATERIALS DISC
hereby affirm under penalty of perjury one of the following ter 6.95 of the
I he Yrequirements under Chap
declarations: I have read the hazardous materials reg 25533,and 25534. I will maintain
maintain a Certificate of Consent to self-insure reCode, or the Worker's Health&Safety Code,Sections 25505,
I have and will 3700 of the Labor � California H Municipal Code,Chapter 9.12 and the Health&
provided for by Section Cupertino
Compensation,
as this perm is issued. compliance with the Cup should I store or handle hazardous material.
performance of the work for which p rovided for by Code,Section 25532(a)
should I use equipment or devices which emit gement District rdous air I will
and will maintain Worker's Compensation Insurance,asp Safety Management
I have Additionally, the Bay Area Air Quality ter 9.12 and the
Labor Code,for the performance of the work for which this contaminants as defined by Municipal Code,Chap
Section 3700 of the liance with the Cupertino
permit is issued. work for which this permit is issued,I shall Health maintal&Safety Code,Sections 25505,25533,and 25534.
I certify that in the performance of the subject to the Worker's
of em loy any person in any manner so as to become I agent:n p this certificate of exemption, Owner or authorized ag Date:
after making I must
Compensation laws of California. If,compensation
o the Worker's Comp provisions of the Labor Code,
become subject t permit shall be deemed revoked.
with comply with such provisions or this p CONSTRUCTION LENDING AGENCY
forth performance of wor
hereby affirm that there is a construction lending agency for the p
APPLICANT CERTIFICATION I h Y
for which this permit is issued(Sec.3097,Civ C.)
read this application and state that the ainformation laws relating Name
I certify that I have and county ordinancesto enter Lenders
correct.I agree to comply With all city
construction,and hereby authorize representatives of this city
to save
to building for inspection purposes.(We) gr ud ents, Lender's Address
upon the above mentioned property of Cupertino against liabilities,j
indemnify and keep harmless the City m consequence of the ARCHITECT'S DECLARATION
may accrue against said City
costs,and expenses which the applicant understands and will comply public records.
granting of this permit.Additionally,
with all non-point source regulations p er the Cupertino Municipal Code,Section I understand my plans shall be used as p
9.18. Licensed Professional
Date
Signature