B-2018-0768 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0768
7965 WOODLARK WAY CUPERTINO,CA 95014-4936(362 03 023) ACME ROOFING
SERVICES INC
LOS BANOS,CA 93635
OWNER'S NAME: DATE ISSUED:05/07/2018
OWNER'S PHONE: PHONE NO:(408)482-3X83
LICENSED CONT'RACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.#1Q21Z9O
Contractor ACME ROOFING.SERVICES INC Date 03/31/2019 X BLDG_ELECT_PLUMB
I hereby affirm that 1 am licensed under 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 force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL OSB;INSTALL COMP SHINGLES
1 hereby affirm under penalty of perjury one of the following two declarations: UNDER PV SYSTEM;INSTALL LIGHT WEIGHT TILE(t2 SQ)
i. I have and will maintain a certificate of consent to self-iname 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,
Gz. 1 heve 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 Arca: Valuation:$7600.00
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 362 03 023
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.
Date 05-07-32018 Issued by:Kim Dunbar
Date:05/07/2018
OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt from the Conh ado's License Law for one of the RE-ROOFS:
following bvo reasons: All roofs shall be inspected prior to any rooting material being installed.If a roof is
a. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove;dl new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code) , �✓/��
z, I,as owner of the property,am exclusively contracting with licensed Signature erAppliea s
contractors to construct the project(See.7044,Business&Professions Code). Date:05-07-32018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation Insurance,as.provided for by I have read the hazardous materials regrdronents node,Chapter 6.95 or tine
Section 3700 ofthe 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
3. I certify that in die performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(,)should I store or handle hazardous
le
shall not em any material.Additionally,should 1 Ilse equipment m'devices which
emit hazardous
employ y p erson in any manner so as to become subject to Ilio r contaminants as defined by the Bay Arun Air Quality Management District 1
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance will'the Cupertino Municipal Code,Chapter 9.12 and
exemption,I became subject to the Worker's Compensation provisions of the fine Health&Safety Code,Sect ns 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:05-07-32018
1 certify that I have read this application and stale 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,Cle 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 ARCLITECT'S DECLARATION
Code,Section 9.18. - 1 understand my plans shall be used as public records.
Signature Date 05-07-32018 Licensed
Professional