10010157 CITY OF CUPERTINO BUILDING PERMIT
CONTRACTOR:LOS GATOS ROOFING PERMIT NO: 10010157
BUILDING ADDRESS: 1118 HOLLYHEAD LN
P O BOX 1726 DATE ISSUED:01/27/2010
OWNER'S NAME: HELMLE LELAND C AND JOANN M
LOS GATOS,CA 95031
IER'S PHONE: 9257596326 PHONE NO:(408)298-9399
CONTRACTOR'S DECLARATION INFO: BLDG ELECT PLUMB
❑ LICENSED CONT BUILDING PERMIT
License Class
Lic.# I—MECH RESIDENTIAL F COMMERCIAL
Contractor Date
f Chapter 9 JOB DESCRIPTION:REMOVE 2 LAYERS COMP.,NO OSB,INSTALL DURATI
ON
I hereby affirm that I am licensed under the provisions o P 30
(commencing with Section 7000)of Division 3 of the Business&Professions COMP.SHINGLES BY OWENS CORNING
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:$4679
Section 3700 of the Labor Code,for the performance of the work for which this Sq.Ft Floor Area:0
permit is issued.
APPLICANT CERTIFICATION
APN Number:36226028.00 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 PERMIT EXPIRES IF WORK IS NOT STARTED
In
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE O
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. Date:
Issued by:
Signature Date
LJ OWNER-BUILDER DECLARATION RE-ROOFS:
b affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any
roofing materialagree remove all new mated.Ifa erials is
I hereby installed without first obtaining an inspection,
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, 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
declarations: HAZARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate of Consent to self-insure for Worker's
provided for b Section 3700 of the Labor Code,for the I have read the hazardous materials requirements under Chapter 6.95 of the
Compensation,as prov Y California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
performance of the work for which this permit is issued. compliance 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
P I shall maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,
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 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 Y
correct.I agree to comply with all city and county ordinances and state laws relating for which this der's Name permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Le
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
,unify 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 understand my plans shall be used as public records.
9.18.
Date Licensed Professional
Signature