B-2018-1296 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1296
7597 PROSPECT RD CUPERTINO,CA 95014-5242(366 24 D6) ULTIMATE ROOFING
SAN JOSE,CA 95128
OWNER'S NAME: DATE ISSUED:08/01/2018
OWNER'S PHONE: PHONE NO;(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lie,#777253
Contractor ULTIMATE ROOFING Date 04/30/2020 X BLDG ELECT_PLUMB
I hereby affirm that I not licensed under the provisions of ChMECH X RESIDENTIAL apter 9(commencing — —
COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and tint my
license is in full force suit effect. JOB DESCRIPTION:
[hereby affirm ander penalty of perjury one of the following two declarations; TEAR-OFF;RE-ROOF;INSTALL OSB;COMP SHINGLE"-(30 SQ)
r. 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 of the work for which this permit is issued.
3700 of the Labor Code,for the performance of the work for which this
permit is issued, Sq.Ft Floor Area: Valuation:$17000.00
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 366 24 036
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 Cuperti Municipal Code,Section 9.18, 180 DAYS FROM LAST CALLED INSPECTION.
Signature, Date 08-1-2018 Issued by:Kim Dunbar
Date:08/01/2018
OWNER-BUILDER DECLARATION
1 hereby sill 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 any roofing material being installed,If a roof is
t. 1,as owner of the property,or my employees with wages as their sole instilled without first obtaining as inspection,l agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for inspection.
sale(Sec.7044,Business&Professions Code)
z. 1,as owner of the property,am exclusively contracting with licensed Signature of Applicant
contactors to construct the project(See.7044,Business&Professions Code). Date:OE-1-2018
I hereby affirm under penalty of perjury one of the following three declarations: AEI,ROOF COVERINGS TO BE CLASS"A"OR 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 Cade,for the
performance of the work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have rood the hazardous nmterbils requirements Order 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 25534.1 will
permit is issued, maintain compliance with the Cupertino Municipal Code,Chapter 9.12 sad the
s. I certify that in the performance of the work for which this permit is issued,l Health&Safety Cade,Section 25532(n)should I store or handle laznrdous
shall not employ any person in any manner so as to become subject to the arterial.Additionally,should 1 use equipment or devices which emit Iazardous
air contaminants as defined by the Bay Area Ali-Quality Management District I
Worker's Compensation laws oFCalifornia.If,after ranking this certificate of will maintain compliance with the Cupertino Municipal Code,Chopter 9.12 snit
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Code,Sections 25505,25533,and 25534.
Labor Code,I must lotthwith comply with such provisions or this permit shall ,
be deemed revoked. Owner or authorized agent:
APPLICAN'1•CERTIFICATION Data:08-1-2018
1 certify that I have read this application and state that the above Information is CONSTRUC'T'ION 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 ARCHITECT'S DECLARATION'
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Dale 08-1-2018 Licensed
Professional