B-2018-1547 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1547
10199 PRADO VISTA DR CUPERTINO,CA 95014-2621(342 14 045) ROOFS BY REVEILLE
INC
SAN JOSE,CA 95126
OWNER'S NAME: WYNHOLDS HANS W AND CANDACE C TRUSTEE DATE ISSUED:09/13/2018
OWNER'S PHONE: PHONE NO:(
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class ROOFING Lic.#1016519
Contractor ROOFS BY REVEILLE INC Date 07/31/2020 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 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 COMP SHINGLES-(28 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.
z. 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 Area: Valuation:$21000.00
APPLICANT CERTIFICATION
I certify that I e r ad this application and state that the above
information' corre .I agree to comply with all city and county ordinances APN Number: Occupancy Type:
and state ws g to building construction,and hereby authorize 342 14 045
represe ati s of hi city to enter upon the above mentioned property for
inspect' n urpo as. e)agree to save indemnify and keep harmless the
City of ertin agai t liabilities,judgments,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may c e a i St sai City i consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Add
it' n Ily,t app' nt and rstands and will comply with all non-point
sour gu ions e C ertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signa r Date 09/13/18 Issued by:Hale c e
Date:09/13/20
DECLARATION
I hereby of�m that I m exempt from the Contractor's License Law for one of the RE-ROOFS:
following t s so : All r4iou
c ed pr or to any roofing material being installed.If a roof is
m. 1,as owner of the property,or my employees with wages as their sole instatainin an ins ection,I agree 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. I,as owner of the property,am exclusively contracting with licensed Signat:
contractors to construct the project(Sec.7044,Business&Professions Code). Date:I hereby affirm under penalty of perjury one of the following three declarations: F CO RINGS TO BE CLASS"A"OR BETTER
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. HAZARDOUS FkAfffkIALS DISCLOSURE
z. 1 have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous erials r quirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Saf Code,S coons 25505,25533,and 25534. I will
permit is issued. maintain compliance wit the o Municipal Code,Chapter 9.12 and the
3. I certify that in the performance of the work for which this permit is issued,I Health&Safety Cod ,S on 2 2(a)should I store or handle hazardous
shall not employ any person in any manner so as to become subject to the material. Additionally s I e e uipment or devices which emit hazardous
air contaminants as e e by a Ba Are Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain comphe Cu ertinfi Municipal Code,Chapter 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Healt Safe o io s 25505,25533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authori a ag
APPLICANT CERTIFICATION Date:09/13/18
1 certify that I have read this application and state that the above information is C TOW LE G A C
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that ther is a con ruction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this rmit is is ued(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 Date 09/13/18 Licensed
Professional