B-2018-1230 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1230
10385 PLUM TREE LN CUPERTINO,CA 95014-2020(316 33 023) CLEAN ROOFING
SAN JOSE,CA 95112
OWNER'S NAME:Ahern James M And Marilynn R Trustee&Et A DATE ISSUED:07/23/2018
OWNER'S PHONE: PRUNE NO:(408)690.6500
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=39 Lic.#103 462
Contractor CLEAN ROOFING Date 12/31/2019 X BLDG_ELECT_PLUMB
I hereby affirm that I am llina sed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license is fn full force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL COMP SHINGLES-(19 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
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 ofthe work for which this permit is issued,
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valuation:$9000.00
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 31633 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 this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all ll non-point
source regulations per the Cupertino Municipal Code,Section 9.1 B. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07/23/2018 Issued by:Jasmine Archbold
Date:07/23/2018
OWNER-BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of the RF-ROOFS•
following two reasons: All roofs shall be inspected prior to any roofing material being installed.IF a roof is
r. 1,as owner ofthe property,or my employees wilt 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 stiuctue is not intended or offered for inspection.
sale owner oft Business&Professions Cade)
owner
z. t,as of the property,a exclusively contracting with licensed Signature o£Applicant:
contraclors to construct the project(Sec,7044,Business&Professions Code), Date:07/23/2018
1 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 t0 self-insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided of 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,and 25534.I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
a. I certify that in the performance o£the work for which this permit is issued,1 Health&Safety Code,Section 25532(x)should I store or handle hazardous
shallt
not employ n remerml.Additionally,should I rise equipment or devices which emit hazardous
p y a y person in any manner so as to beconre subject to the air contaminants as defined by the Bay Area Air Quality Management District 1
Worker's Compensation laws of California.If,offer making this certificate of will maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and
exemption,1 become subject to the Worker's Compensation provisions of the flue Health&Safety Code,Sections 25505,25533,and 25534.
Labor Cade,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent2/� `—
APPLICANT CERTIFICATION Date:07/2312018,
I certify that I have read this application and state 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,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 ARCHiTEC'f'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 07123/2018
Professional