B-2018-0826 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0826
10836 LINDA VISTA DR CUPERTINO,CA 95014-4749(356 14 050) PREH INC
LOS GATOS,CA 95031
OWNER'S NAME: DATE ISSUED:05/14/2015
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=39 Lic.#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 of the Business&Prot'esslons Cede and that my
license is in tail force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL OSB;INSTALL COMP-(25 SQ)
1 hereby affirm ander 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
performance of the work for which this permit is issued.
2. 1 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 chis
1 permit is issued. Sq.Ft Fluor Area: Valuation:$11000.00
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 Typo:
and state laws relating to building construction,and hereby authorize 356 14 050
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-point
source regulations per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signafuree � Date 05/14/2018 Issued by:Jasmine Archbold
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Data:05/!4/2018
OW NF,II-BUILDER DECLARATION
I hereby affirm that I am exempt from the Coutrada's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prier Ir 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 far inspection.
sale(Sec.7044,Business&Professions Code)
z. I,as owner of the properly,am exclusively contracting with licensed Signature of Applicant:
contractors to construct the project(Sce.7044,Business&Professions Code), Date:05/14/2018
1 hereby affirm under penalty of perjury one of the following(utas declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. I have and will maintain a Certificate of Consent to self-insure for Wca or"s
Compensation,as provided for by Section 7700 of the Labor Code,for the
performance of the work too which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. i have and will maintain Worker's Compensation Insurance,as provided Earthy I hove read the hazardous materials requirements under Chapter 6.95 f the
Section 3700 of the Labor Code,for the performance of flic work Ito which this California Health&Safety Code,Sections 25505,25533,mad 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532bo should I Stora at handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additlunally,should 1 use equipment or devices which emit hazardous
mr contaminants its defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California,If,after making this certificate of will maintain eonapifanee with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Cade,Sections 25505,25533,and 25534.
Labor Code,I mast forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:05/14/2018
1 certify that I have read this application and state that the above information is CONSTRUCTION LENDING AGENCY
correct.I agree to comply will)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,casts,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. 1 understand my plans shall be used as public records.
Licensed
Signature
Data 0 5/1 412 01 8 Professional