B-2018-0952 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0952
20644 ACADIA CT CUPERTINO,CA 95014-1756(326 56 018) WESTSHORE
ROOFING I
31
OWNER'S NAME:MORDO DAVID AND ARI DATE I 18
OWNER'S PHONE:408-252-1985 PHONE NO:(408)456-0200
LICENSED CONTRACTOR'SDECLARATION BUILDING PERMIT INFO:
License Class Q.0 Lia#287221
Contractor WESTSHORE ROOFING INC Date 11/30/2018 X BLDG_ELECT—PLUMB
1 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:
RE-ROOF;TEAR-OFF;INSTALL METALTILES(38 SQ)
I hereby affirm under penalty of perjury Due o£the following two declarations: CLASS A ASSEMBLY(3)SEE ICC SHEET ESR-1491-4A.1.5
v I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Sec
s provided for by
1 L Section 3700 of the Labor Code,for the performance of the work for which this
v permit is issued, Sq.Ft Floor Area: Valuation:$32000.00
APPLICANT CERTIFICATION
I certify that I have read this appllcatlon and state that the above
information is correct.I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and stale laws relating to building construction,and hereby authorize 326 56 018
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 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- int
source regulations per the Cuper'no Municipal Code,Section 9.18. 1.80 DAYS FROM LAST CALLED INSPECTION.
Signature � � Date 06-04-2018 Issued by:Kim Dunbar
Date:06/04/2018
OWNER-BUIL.D'CLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following ben reasons: All roofs shall be inspected prior to any roofing material being installed.Its roof is
r, 1,as owner of the property,or my employees with wages as their sole nstall
ffered for ;{'sspectio
sale owner
oft Business&Professions Code) 2I1101I\
z I,nt owner of the struct the pr exclusively contracting with licensed Signature 4-2018icant Ili w,
contractors to construct the project(Sec,7044,Business&Professions Code). Date:OC-04-2018
1 hereby affirm under penalty of perJury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
r. 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
1. 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 of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additlonally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this cenifteate of ryHJ matotaln compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become s to the Worker's Compensation provisions of the the Health&Safety Cod SeOkins 25 0 25533,a 5534.
Labor Cade,l must forthwith comply with such provisions or this permit shall
be deemed revoked Owner or authorized agent: l - K/
APPLICANT CERTIFICATION Date:06-04-2018
I certify that I have read this application and state that the above Information Is CONSTRUCTI N LEN ING 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 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 complywith all non-point source regulations per the Cupertino Municipal ARCHITECT'S DECLARA'IJON
Code,Section 9.18. understand my plans shall be used as public records.
Licensed
Signature Date 06-04-2018 Professional