B-2018-1126 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PFRo,11T NO:B-2018-1126
11734 RIDGE CREEK CT CUPERTINO,CA 95014-5154(366 04 038) IIREH INC
LOS GATOS,CA 95031
OWNER'SNAME:CHAN PAUL K AND CINDY S TRUSTEE DATE ISSUED:07/03/2018
OWNER'S PHONE: PHONE NO:(408)298-9399
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 B 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&Professions Code and that my
license is in frill force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR OFF;COMP SHINGLES(26 SQ)
I hereby affirm under penalty of perjury one of the fallowing two declarations:
u I have and will maintain a certificate of cousent to self-inswe for Worker's
Xr-1.V-,
ensation,esprovided for by Section 3700 of the Labor Code,for the
ecrmetes of the work for which this permit is issued.
e and will maintain Worker's Compensation Insurance,as provided for by
S ion 3700 of the Labor Code,for the performance of the work for which this
permit is bared. Sq.Ft Floor Area: Valuation:$1100.00
APPLICANT CERTIRICATION
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: Occupancy Type:
and state laws relating to building construction,and hereby authorize 366 04 038
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 pplicant understands and will comply with all non-point
source regulatlo s perthe Cupertino Municipal code,Seedon 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 7-3-2018 Issued by:Kim Dunbar
Date:07/03/20 t 8
OWNER- ILDER 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 auy roofing material being installed.If n roof is
r. I,as owner of the 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 for .�,
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). Date:7-3-2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL-ROAR,COVERINGS TO-BE-CLASS-W OR-BETTER
knave and wit mauntam aertiicate oonsent to se -aiamc or or ccr s
Compensation,as provided for by Section 3700 of[he Labor Code,fmthe
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
2. I have and will maintain Worker's Compensation lusumnce,as provided for by I have read the hazardous uaterinls requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance o£the work far which this California Health&Safety Code,Sections 25505,25533,and 25534.twill
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&Safety Code,Section 25532(a)should 1 store or handle hazardous
shall not employ ally person in any manner so as to become subject to the material.Additionally,should I use equipment at-devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
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 became subject to the Worker's Compensation provisions of the the Health&Safety Code,5ctions 25505,255 8 and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CE;frIFICATION Date:7.3-2018
I certify that I have read this application and stale that the above Information is CONSTRU 'ION LENDING AGENCY
correct.I agree to comply with all city and county ordinances and stale laws I hereby affirm that there Is aconstructlon lending agency for the performance
relating to It 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 ARCHITECT'S D�C�A1RsriON
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 7-3-2018 professional '