B-2018-1134 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1134
21416 HOLLY OAK DR CUPERTINO,CA 95014-4928(362 02 035) BAY 101 ROOFING INC
ALVISO,CA 95002
OWNER'S NAME:COLE CAROL K TRUSTEE DATE ISSUED:07/05/2018
OWNER'S PHONE: PHONE NO:(408)957-0531
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 Lie.#907116
Contractor BAY 101 ROOFING INC Date 11/30/2019 X BLDG_ELECT_PLUMB
MECH X RESIDENTIAL COMMERCIAL
I hereby affirm that I am licensed under the provisions of Chapter 9(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;INSTALL OSB;COMP SHINGLES-(26 SQ)
I hereby affirm under penalty of perjury one of the following 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,
�1 f t—zr I have 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 Floor Arca: Valuation:$14450.00
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 36202 035
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:.G erlin unicipal Code,Section 9,18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07/0518 issued by:Haley McKee
Date:07/05/2018
OWNER-BUILDER�, C_� ATIO
thereby affirm(bottom exempt from the Contractor's License Law for one of theRP ROOFS:
following hvo reasons: All roofs shall be inspected prior to any roofing material being installed.He of is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining an inspection,l a rcc to m move all new materials for
compensation,will do the work,and the structure is not intended or offered for it a tial
sale(Sec.7044,Business&Professions Code)
x. I,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). Date:07/05118
1 hereby affirm under penalty of perjury one of the following three declarations: pLL ROOF COVERINGS TO BE CLASS"A"OR BETTER
�. i-have-and-will-maintain-a-eertificatemf-C—onsentto-selfinsme-forWorker'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
c. 1 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 die Labor Cede,for the performance of dw 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
s. I certify that in the performance of the work for which this permit is issued,I Hedth&Sxfety Cede,Section 25532(x)should I store or handle hazardous
d
shall not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment or devices which emit hazardous
air contaminants as defineby 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 CuperRno Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions ofthe the Health&Safety Code,Sections2mr/
I certifythat I have read this application and slate that the above Information Is CONSTRUCTION LE AGENCY
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a constructiorflencing 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 Munlcipal ARCHITECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureDate 07/0518 Licensed
Professional