B-2016-1878 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2016-1878
19866 BEEKMAN PL CUPERTINO,CA 95014-2451(316 30 122) ARMSTRONG
INSTALLATION
SERVICE
EMERYVILLE,CA
94608
OWNER'S NAME: DATE ISSUED:05/03/2016
OWNER'S PHONE: PHONE NO:(510)777-1234
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class ROOFING Lic.#245291
Contractor ARMSTRONG INSTALLATION SERVICE Date 11/30/2016 X BLDG _ELECT _PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing — —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
REMOVE T&G;(NO PLY)INSTALL FOAM OVERLAY(12 SQ'S)
I hereby affirm under penalty of perjury one of the following two declarations:
1. 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
is issued. Sq.Ft Floor Area: Valuation:$11848.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above APN
information is correct.I agree to comply with all city and county ordinances 1630 122
Number: Occupancy Type:
3
and state laws relating to building construction,and hereby authorize 316
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,costs,and expenses which PERMIT EXPIRES IF FORK IS NOT STARTED
may accrue against saidCi in consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant derstands and will comply with all non-point
source Code,Section 9.18. 180 DAYS FROM L PECTIN.
Signatur. Date 05/03/2016 Issued by:MELISSA NAM
Date:05/03%2016
DER DE TI
Iv
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any r ofmg material being installed.If a roof is
i. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an insp tion,I agree to r ove all new materials for
compensation,will do the work,and the structure is not intended or offered for � .
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of
Ap
contractors to construct the project(Sec.7044,Business&Professions Code). Date:05/03/2016
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
1. 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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as provided for by I have read)the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of-the work for which this California Health&Safety Code,Sections 25505,25533,and 25534. I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Health&Safety Code,Section 25532(a)should I store or handle hazardous
a. I certify that in the performance of the work for which this permit is issued,I
shall not employ any person in any manner so as to become subject to the material. Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air uality Management District I
Worker's Compensation laws of California. If,after making this certificate of K maintain compliance with the Cupertino nicipaI Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized ag
APPLICANT CERTIFICATION Date:05/03/2016
I certify that I have read this application and state that the above information is CON TRUtCTION LEND A ENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lendinj a ency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit. Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal AF. T'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 05/03/2016