B-2018-0689 (3) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0689
10221 STONYDALE DR CUPERTINO,CA 95014-1029(326 37 018) JIREH INC
LOS GATOS,CA 95031
OWNER'S NAME:WEINBERG RICHARD AND TARA DATE ISSUED:04/26/2018
OWNER'S PHONE: PHONE NO:(408)298-9399
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C_39 Lia#800707
Contractor JIREH INC Date 10/31/2019 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 attire Business&Professions Code and that my
license is in fail force and effect. JOB DESCRIPTION:
TEAR-OFF;RE-ROOF;INSTALL OSB;COMP SHINGLES-(42 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
u I have and will maintain a certificate of consent to self-insure for Workers
Compensation,as provided for by Section 3700 of the Labor Code,for the
erformance of the work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,is provided for by
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$14279.00
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above AVIS Number: Occupancy Type;
information is correct.I agree to comply with all city and county ordinances
and state laws relating to building construction,and hereby authorize 32637 018
represenlallves 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 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 per�no Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature ,at 04-26-2018 Issued by:Kim Dunbar
Date:04/26/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All root's shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner of the 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 °t1O0'
sale(Sec,7044,Business&Professions Code)
a. I,as owner of the property,am exclusively contracting with licensed Signature ofApl icaut
contractors to construct the project.(Sce.7044,Business&Professions Code). Date 04-26-2018
1 hereby affirm under penalty of perjury one of the following three declarations:
1. I have cad will maintain a Certificate of Consent t°selfn-Iime for WorkCY's ALL ROOF
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
1, I have and will maintain Worker's Compensation Insurance,as provided far by I have,cad the hazardous materials requirements under Chapter 6.95 of the
Section 3700°f'the Labor Code,for the performance of the work for which this California Health&Safety Code,Sectlons 25505,25533,and 25534.1 will
permit is Issued. midirum n complbmcewith the Cupertino Mmt illail Code,Chapter 9.12 and Bre
3. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Sectloo 25532(x)should 1 store or handle hazardous
shall not employ any person in any manner so as to becoutc subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
ontaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of Califomia,If,after making this certificate of wit-ill maintain compliance with the Capin Unit Munidpal Code,Chapter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections '5505,25533,smd 25 4.
Lobe,Code,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent��
APPLICANTCERT Date:04-26-2018
I certify that I have read this application and state that the above information is CONSTRUCTION
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,ON 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 MunicipalARCHITECT'S DECLARIION
Code,Section 9.18. understand my plans shall be used as public records.
Licensed
Signature Data 04-26-2018 Professional