10080183 CITY OF CUPERTINO BUILDING PERMIT
RLDING ADDRESS: 7457 DE FOE DR CONTRAC TOR:WESTSHORE ROOFING PERMIT NO:10080183
INC
2245-A Fol
DR DATE ISSUED:08/26/2010
`'1TER'S NAME: ANDERSEN EGIL AND LINDA M PHONE NO:(408)694-0060
SAN JOSE CA 95131
vVNER'S PHONE: 4088610982
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
Fr—
COMMERCIAL r
cense Class Lic.# MECH RESIDENTIAL
Date AKE ROOF
ontractor
JOB DESCRIPTION:REMOVE EXISTING 2 LAYERS WOOD SH
hereby affirm that I am licensed under the provisions of Chapter 9 ERAS S TONE COATED STEEL ROOF SYSTEM CLASS A
:ommencing with Section 7000)of Division 3 of the Business&Professions GERARD S!ON ESR 1491
'ode and that my license is in full force and effect.
APPLICAhereby affirm under penalty of perjury one of the following two declarations:
have and will maintain a certificate of consent to self-insure for Worker's
;ompensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued.
have and will maintain Worker's Compensation Insurance,as provided for by
lection 3700 of the Labor Code,for the performance of the work for which this FAPN
t Floor Area:0 Valuation:$18918
permit is issued.
APPLICANT CERTIFICATION Occupancy Type:
certify that I have read this application and state that the above information is Number:35924014.00
;orrect.I agree to comply with all city and county ordinances and state laws relating
:o building construction,and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, PERMIT EXPIRES IF WORK IS NOT STARTS
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section 18C DAYS FROM LAST CALLED INSPECTION.
9.18.
Date:
matu
Date-- Issued by:
re
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following two reasons:
I,as owner of the property,or my employees with wages as their sole compensation, installed without first obtaining an inspection,I agree to remove all new materials or
will do the work,and the structure is not intended or offered for sale(Sec.7044, inspecti(n.
Business&Professions Code) Signatui a of Applicant: Date:
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
Compensation,as provided for by Section 3700 of the Labor Code,for the I have 1•ead the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by compli ince with the Cupertino Municipal Code,Chapter 9.12 and the Health&
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
t will
permit is issued. ed by the Bay
I certify that in the performance of the work for which this permit is issued,I shall maint2 n compliance nwith the Cupertineo Muni�cipaltCode,rChapter 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
become subject to the Worker's Compensation provisions of the Labor Code,I must Ow,nei or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I herel Py 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 wl ch this permit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Lendi is Name
i
the above mentioned property for inspection purposes.(We)agree to save
� .unify and keep harmless the City of Cupertino against liabilities,judgments, Lend pr's Address
costs,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
9.18. 1 und.:rstand my plans shall be used as public records.
Signature
Date Licensed Professional