B-2018-0893 CITY OF CUPERTINO BUILDING PERMIT
BU ILDINGADDRESS: CONTRACTOR: PERMIT NO:B-2018-0893
10447 MERRIMAN RD CUPERTINO,CA 95014-2680(342 29 052)10445 MERRIMAN WORKFORCE
RD CUPERTINO,CA 95014-2680(342 29 052) ROOFING W F R
SAN JOSE,CA 95133
OWNER'S NAME: DATE ISSUED:05/23/2018
OWNER'S PHONE: PHONE NO:(408)892-5096
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class.Qn Lic.#916M
Contractor WORK FORCE ROOFING W F R Date 01/31/2020 X BLDG ELECT_PLUMB
1 hereb filrm that I um licensed under the provisions of Chapter 9 _MECH X RESIDENTIAL_COMMERCIAL
y a p p (commencing
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;COMP SHINGLES(47 SQ)DUPLEX
I hereby affirm under priority of perjury one of the following two declarations;
L 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
z 1 have and will maintain Worker's Compensation Insurance,as provided for by
RI AA Section 3700 of the Labor Code,for the performance of the work for which this
"t permit is issued. Sq.h4 Floor Area: Valuation:$19634.73
APPLICANT CERTIF'CAT'ON
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 34229 052
representatives of this cilyto enter upon the above mentioned property for
Inspection purposes.(Wei)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-polnt
source regulations per the Cupertino Municipal Code,Section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06-23-2018 Issued by:Kim Dunbar
Date:05/23/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Low to,.one of the RE-ROOFS:
Inferring two reasons: All roofs shall be inspected prior to any roofing material being installed.To roof is
1. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,1 agree to remove all new materials for
compensation,will do the work,and the struchue is not intended of offered far inspection'
sal,(Sea.7044,Business&Professions Cade)
z. 1,as owner ofthe property,am exclusively contracting with licensed Signato—I'ApplicanC
contractors to construct the project(Sec.7044,Business&Professions Code), Date:05-23-2018
1 hereby affirm under penalty of perjury one of'the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
L 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 the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. 1 have and will maintain Worker's Compensation Insurance,as provided rot by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the perfarmance of the work for which this Califm-nia Iiealth&Safety Code,Sections 25505,25533,and 25534.twill
permit is issued. n lith n compliance with file 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 25532(,)should I store or handle hazardous
all;,[] of employ any person in any manner so as to become subject to the material.Additionally,should 1 ase equipment or devices which emit hazardous
air contaminants as defined by the tiny Area Air Quality Management District 1
Worker's Compensation laws of California,If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Cade,l most forthwith comply with such provisions or this permit shall
APPLICANT CERTIFICATION Date:05-23-2018
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'SllECLAAlr"011
Code,Section 9.18. 1 understand my plans shall be used as public reRcords.
Licensed
Signature Data 05-23-2018 Professional