B-2018-1011 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-201.8-1011
920 SAGE CT CUPERTINO,CA 95014-4217(359 06 008) CUPERTINO ROOFING
INC
SAN JOSE,CA 95129
OWNER'S NAME: DATE ISSUED:06/13/2018
OWNER'S PHONE: PHONE NO:(408)973-9427
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=39 Lic.#565437
Contractor CUPERTINO ROOFING INC Date 03/31/2020 X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed ander 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 farce and effect. JOB DESCRIPTION;
RE-ROOF;TEAR-OFF;INSTALL OSB;INSTALL COMP SHINGLES-
I hereby affirm under penalty of perjury one of the following two declarations: (23 SQ)
t,-8have and will maintain a certilicatc of consent to self-insure for Worker's
�
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
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 slate laws relating to building construction,and hereby authorize 359 06 008
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
AdditionaLyyJ�the applicant understands and will comply with all non-point
source regulalibn per
the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6/13/2018 Issued by:Jasmine Archbold
Date:06/13/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt front the Cort actor's License Law for one of the u-'-" RE-ROOFS:
following two reasons: All roofs shall be inspec(lM m for to any roofing material being installed,Ira roof is
t. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining;r t inspection,l agree to remove all new materials for
compensation,will do the work,and the structure is out intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner ofthe property,am exclusively contracting with licensed Signature of Applicant: •/
contractors to construct the project(Sec.7044,Business&Professions Code). Date; 16/3/20t8
1 hereby affirm odor penalty of perjury one of the following three declarations: ALJ..R OF COVERINGS TO BE CLASS"A"OR BETTER
r. 1 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 die work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. 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 25534.1 will
permit is issued. m aintain compliance with the Cupertino Municipal Code,Chapter 9,12 and the
s. I certify that in the performance of the work far which this permit is issued,I Health&Safety Cade,Section 25532(x)should 1 store or handle hazardous
shall not employ an manner so as to become subject to the material.Additionally,should 1 use equipment or devices which emit hazardous
l y y person in any m J contaminants as defined by the Day Area Air Quality Management District[
Worker's Compensation laws of Califarnin.If,after making this certificate of will maintain compliance withlbe—Cupur,""Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cc e,Sectio s 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Data:6113/20 1 a
I certify that I have read this sipplioation 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 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 to 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 UICCI,ARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 6113/20 8 Licensed
Professional