B-2018-1071 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1071
7611 HOLLANDERRY PL CUPERTINO,CA 95014-5070(362 26 065) WESTSHORE
ROOFING INC
OWNER'S NAME:Cui Gump And Yang Mingtao SUED:06/26/20
HONE:650-318-9572 PHONE NO:(408)456-0200
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class ROOFING LIc,#Z87221
Contractor WESTSHORE ROOFING INC Dale 11/30/2018 X BLDG ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECI4 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;IB ROOF OVERLAY-(5 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
u 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
JL Section 3700 of the Labor Code,for die performance of the work fm which this
4l 1 permit is issued. Sq.Ft Firm-Area: Valuation:$6000.00
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 26 065
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
Additiona d will comply with all non-point
source regulations per thee(\CCuperti to Municipal Code,Section 9.16. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 0 612 612 01 8 Issued by:Jasmine Archbold
Date:06/26/2018
OWNER-BUILDER ECLARATION
I hereby affirm that I am exempt from the Contractor's License Lmv tor one of theRE-ROOFS:
following two reasons: All roars shall be inspected prior to any roofing material being installed.If a naafis
r. 1,as owner of the property,oi my employees with wages as their sole undated without fust obtaining on inspection,I agree to remove all
ess&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature ofAppli.n.
contractors to construct the project(See.7044,Business&Professions Code), Date:06/26/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALLIR COVERINGS TO BE CLASS"A"Oli BETTER
t. 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 pat art is issued. HAZARDOUS MATERIALS DISCLOSURE
a 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,-1 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. I certify that in the performance ofthe work for which this permit is issued,I Health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment ar devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.trotter making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of th
evoked, Owner or authorized agent: t
APPLICANT CERTIFICATION Date:06!26!2018
certify that I have read this application and state that the above Information is CONSTRD ION L A ENCY
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. 1 understand my plans shall be used as public records.
Signature Data 06!26!2018 Licensed
Professional