B-2018-0177 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS:. CONTRACTOR: PERMIT NO:B-2018-0177
21517 RAINBOW DR CUPERTINO,CA 95014-4816(356 23 024) MILLER'S ROOFING
SAN JOSE,CA 95124
OWNER'S NAME:SRIKUMAR KESAVAN AND SUNEETA DATE ISSUED:01/26/2018
OWNER'S PHONE: PRONE NO:(408)356-6211
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.#88501 B
Contractor MILLER'S ROOFING Date 09/30/201 B X BLDG_ELECT_PLUMB
I herebyaffirm that I am licensed under the i ovisfo rs of Cbn ter 9 _MECH X RESIDENTIAL_COMMERCIAL
p p (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-(33 SQ)
I hereby affirm under penalty of perjury one ofthe following two declarations:
r. 1 have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
per of the work for which this permit is issued,
z. I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
C/Jl`y
per is issued, Sq.Ft Flom•Are.: Valuation:$15500.00
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 35623 024
representatives of this city to enter upon the above mentioned property for
Inspectlon purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said city In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source regulations p/erthe Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature !/- Date 01-26-2018 Issued by:Kim Dunbar
Date:01/26/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roof's shall be inspected prior to any roofing material being installed If a roof is
r. 1,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove 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 ofthe property,am exclusively contracting with licensed Signature ofAppliriad
contractors to construct the project(Sec.7044,Business&Professions Code), Date:01-26-2018
I hereby affirm under penalty of perjury one of tire following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER1. 1 have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 ofthe Labor Code,for the
performance of Ole work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z 1 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 or the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
mit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
per a
a. 1 certify that in the performance ofthe work for which this penult is issued,l Health&Safety Code,Section 25532(x)should I store or handle hazardous
nraterfai.Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to became subject to the air contaminants as defined by the Buy Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will ranintain compliance with the Cupertino Municipal Code,Chaptcr 9.12 and
exemption,I become subject to the Worker's Compensation In of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANTCERTIFICATION Date:01-26-2018 —c-
I certify that I have read this applioatlon and State that the above Information Is CONSTRUCTION LENDING AGENCY
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 thls 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 Ilablllties,
judgments,costs,and expenses which may accrue against said Chy 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. 1 understand my plans shall be used as public records.
Licensed
Signature Data 01-26-2018 Profess lonal