B-2018-1120 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1120
11223 LA JOLLA CT CUPERTINO,CA 95014-4738(356 21 044) WESTSHORE
ROOFING INC
SAN JOSE,CA 95131
OWNER'S NAME:Canton Carnation M Trustee DATE ISSUED:07/03/2018
OWNER'S PHONE: PHONE NO:(408)4560200
LICENSED CONTRACTOR'S DECLARATION _ BUILDING PERMIT INFO:
License Class CC=39 Lic.#787221
Contractor WESTSHORE ROOFING INC Date 11/30/2018 x BLDG ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Chxpter 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;1NSTALLASPHALT SHINGLES
I hereby affirm under penalty of perjury one of the following two declarations: (28 SQ)
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.
3[— 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 Flom Area: Valuation:$18320.00
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: Occupancy Type:
and slate laws relating to building construction,and hereby authorize 35621 044
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-point
source regulations per the Cupertino Muni'paI C
"Date 07/03/2018 Issued by:Jasmine Archbold
Date:07/03/2018
O ER- D f DIAIIATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the -ROOFS,
following two reasons: All roofs shall be inspected prior to any roofing material being installed Rattail
is
r. I,as owner of the property,or my employees with wages as their sole installed without first obtaining an his I agree to remove all new restm�ialy for
• compensation,will do the work,and the an re ure is not intended or offered for lion.
sale(Sec.7044,Business&Professions Code) ��•
z. I,as owner of the property,ma exclusively contracting with licensed Signature of Applicant
contractors to construct the project(Sec.7044,Business&Professions Code). -Da07/03129 I8
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
t. 1 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 ofdue 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 theft rc irs nmtcrials 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
pernriI is Issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
3. 1 certify that in the performance of the work for which this permit is issued,I Health&Safety Cotte,Section 25532(.)A Id I 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
r contaminants its defined by the Bay Area Air Quality Management District I
Worker's Compensation laws o£California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Clmpter 9.12 and
exemption,I become subject to the Walker's Compensation provisions of the the Health&Safety Cod,Sections 25505,25533,and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:_
APPLICANT CERTIFICATION Date:07/03/2018
1 certify that I have read this application and stale that the above information is CONISTRUC UNIT GAGENCY
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 0 7/0 372 0 1 8 Licensed
Professional