B-2018.0841 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0841
22630 SAN JUAN RD CUPERTINO,CA 95014-3989(342 18 004) ACME ROOFING
SERVICES INC
LOS BANOS,CA 93635
OWNER'S NAME: DATE ISSUED:05/16/2018
OWNER'S PHONE: PHONE NO;(
LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 Lic.#1001790
Contractor ACME ROOFING SERVICES INC Date 03/31/2019 X BLDG ELECT PLUMB
1 hereby affirm that[am licensed underthe provisions of Chapter 9(commencing —MECIT 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 COMP SHINGLES-(1 I SO)
1 hereby affirm under penalty of perjury one of the fallowing 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.
Section 3700 of the Labor Code,for the performance o£the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$0.00
APPLICANT CERTIFICATION
I certify that I have read this application and slate that the above -- --
information is correct.I agree to comply with all city and county ordinances APN Number: Occuptrucy'type:
and state laws relating to building construction,and hereby authorize 342 18 004
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 WORI{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-paint
source regulatiiionnsss pp rho Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature 1/`�`�� �---- Date 05116/2018 Issued by:Jasmine Archbold
Date:05/16/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If.roof is
r. I,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 far
compensation,will do the work,and the structure is cat intended or offered for
(See.7044,Business&Professions Code)
x. i,as of die property,am exclusively contracting with licensed Signature ofApplicant:
contractors to construct the project(Sec.7044,Business&Professions Code), Date:05/16/2018
t hereby affirm trader penalty of perjury one of the following three declarations: ALL 1200E 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 of the Labor Code,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
i. 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.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance of the work for which this permit is issued,I Health&S.cry Code,Section 25532(x)should 1 store or handle hazardous
shall not employ any person m any manner so as to become subject to the material.Additi omlly,should I use equipment or devices which emit hazardous
air contaminants us defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws ofCnllfornia, If,eller making this cettificate of will maintain compliance with the Cupertino Municipal Cade,Chapter 9.12 and
emption,l become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sec 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 Date:05/1612018
1 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'SDECLARATION
Coda,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 05116/2018 Licensed
Professional