B-2018-0941 CITY OF CUPERTINO BUILDING PERMIT
BE ILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0941
10249 PASADENAAVE CUPERTINO,CA 95014-5920(357 18 037) ROOF ROOFING INC
SAN JOSE,CA 95118
OWNER'S NAME:IMAI PROPERTIES,LP DATE ISSUED:05/31/2018
OWNER'S PHONE: PHONU NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 Lic.#687568
Contractor ROOF ROOFING INC Date 0713112019 X BLDG—ELECT—PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed tinder the provisions of Chnpter 9(commencing
with Section 7000)at'Division 3 of the Business&Professions Code and that my
license is in full farce and effect 30B DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL OSB;COMP-SHINGLES(15 SQ)
I hereby affirm corder penalty of perjury one of the following two declarations:
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
if.
fom
ranca of the work for which this permit is issued.
'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 Fluor Arco: Valuation:$7000.00
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 357 18 037
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 w'H comply with all non-point
source regulations per the c pert[ - a pal Code,s ctlon 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signatur Date 5-31-2018 Issued by:Kim Dunbar
����� Date:05/31/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS
following twti reasons: All root's shall be inspected prior to any roofing material being installed,If..of is
1. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I afire emcve all new materials for
compensation,will do the work,and the structure is not intended or offered for pecti x
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the property,am exclusively contracting with liccnsod Signature of Apphcan'
contractors to const net the project(Sec,7044,Business&Professions Code), Date:5-31-2018
I hereby affirm mrder penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. I 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 ofthe 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 ofthe
Section 3700 ofthe Labor Code,for the performance ofthe work for which this California Health&.Safety Code,Sectlmrs 25505,25533,and 25534.1 will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 212 and the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safely Code,Section 25532(a)should 1 store or handle bazardans
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate or will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions ofthe the Heulth&Safety Code,Sections 245 S, 5 s and 25534.
Labor Code,I most forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPI,ICANT CJ,'RTIFICATION Date:5-31-2018
I certify that I have read this application 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 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 5-31-2018 professional