B-2018-1394 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO;B-2018-1394
6116 WILLO WGROVE LN CUPERTINO,CA 95014-4649(375 38 016) COSMOS ROOFING
INC
MOUNTAIN VIEW,CA
94043
OWNER'S NAME: DATE ISSUED:08/17/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.#785441
Contractor COSMOS ROOFING INC Date 04/30/2019 X BLDG_ELECT_PLUMB
I hereby affirm that[am licensed ander[he provisions of Chapter 9(commentiMECH X RESIDENTIAL ng — — _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 TAR&GRAVEL-(1900 SF)
I hereby affirm under penalty of perjury one of the following two declarathoua
r. I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided for by Section 3700 of rhe Labor Codc,for rhe
' performance of the work for which this permit is issued.
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 Area: Valuatimu$10375.00
APPLICANT CEItT1FICATION
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 All Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 37538 016
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,casts,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 and ds and will comply with all non-point
source regulations per e C cutin unicipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 08/17/2018 Issued by:Jasmine Archbold
Date:08/17/2018
OWNER-BUILDER DECLARATION
I her 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 an oefing material being installed.If u.of is
r, I,as owner of the property,or my employees with wages as their sole installed without first obtaining a nspectio gree 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 ofApplicmhl:
contractors to construct the project(Sec.7044,Business&Professions Code). Date;08/17/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"A"OR BETTERr. I have mrd will maintain a Certificate of Consent to self insure for Worker's
Compensation,as provided for by Section 3700 of die Labor Code,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 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
m
permit is issued. aintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s. l certify That in tlhe performance of the work for which this permit is issued,I health&Safety Code,Section 25532(a)should 1 store or handle hazardous
shill not employ any person in any manner so as to become subject to the material.Additionally,should I use equipment ..d c which emit hazardous
Worker's Compensation laws o£California.If,after making this certificate of air contnminnnfs ns defined by the Bay Are Air QualiteS s agement District 1
P 6 will maintain wmplinncc with the Caper
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:08/17/2018
1 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 ARCHITECT' DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 08117!2018 Licensed
9 Professional