B-2017-2016 CITY OF CUPERTINO BUILDING PERMIT
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BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2017-20I6
7920 AUGUST LN CUPERTINO,CA 95014-4113(362 12 017) CUPERTINO ROOFING
INC
E,CA 95129
OWNER'S NAME: NARAYAN ANANT L DATE ISSUED: 11/22/2017
OWNER'S PHONE:408-973-9807 • PHONE NO:(408)973-9427 •
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: .
License Class C39 Lic.#565437
Contractor CUPERTINO ROOFING INC Date 03/31/2018 X BLDG _ELECT _PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
• RE-ROOF:TEAR-OFF;INSTALL OSB:COMP SHINGLES-(27 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
1. I.h for Worker's ,
Compensation,as,provided for by Section 3700 of the Labor Code,for the
formance of the work for which this permit is issued.
2 ve and will maintain Worker's Compensation Insurance,as provided for by
er
5ection 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$15000.00
APPLICANT CERTIFICATION
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize - 362 12 017
representatives of this city to enter upon th
80 DAYS OF PERMIT ISSUANCE OR
Additionally,the as licant understands and will comply with all non-point
source reg lations p r the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LA
aterials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code) r
2. I,as owner of the property,am exclusively contracting with licensed Signature ofApplica '. ifik_
' contractors to construct the project(Sec.7044,Business&Professions Code). Date:11-22-2017
I
• 1 hereby affirm under penalty of perjury one of the following three declarations: ' e OF 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. aintai ompliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. I certify t
air contaminants as defined . th'e Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the . the Health&Safet Code Sections 25;5,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized age a(r •. _I
APPLICANT CERTIFICATION Date:11-22-2017 r
I certify that I have read this application and state that the above information is ' TR TI e k LE DI A E►
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency 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 ARCHITECT'S DECLARATION
Code,Section 9.18. I understand my plans shall be used as public records.
Licensed
Signature Date 11-22-2017 Professional •