B-2018-1789 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO: B-201.8-1789
19070 BARNHART AVE CUPERTINO, CA 95014-3502 (375 37 035) WESTSHORE
ROOFING INC
SAN JOSE, CA 95131
OWNER'S NAME: DATE ISSUED: 10/19/2018
OWNER'S PHONE: PHONE NO; (408) 456-0200
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 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 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:
I hereby affirm under penalty of perjury one of the fallowing two declarations: RE-ROOF; TEAR-OFF; INSTALL COMP SHINGLES - ( 23 SQ)
1. 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.
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: $13045.00
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 375 37 035
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
Additionally, the applicant understands and will omply with all non-point OF PERMIT ISSUANCE OR
source reg anon peleCupertin unici I C de, Section 9. 18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 10/19/2018 Issued by: Jasmine Archbold
Date: 10/19/201 $
OWNER-BUILDER DECLARATION
I hereby 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 any roofing material being installed. If a roof is
1. I, as owner of the property, or my employees with wages as their sole installed without first obtaining all inspection, I agree to.,i; ve all new materials for
compensation, will do the work, and the structure is not intended or offered for �'
contractors to construct the project (See.7044, Business & Professions Code). Date: 10/19/2018
I hereby affirm under penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
1. 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 MATERIALS DISCLOSURE
2. 1 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
permit is issued. maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
3. I certify that in the performance of the work for which thisennit is issued I Health & Safety Code, Section 25532(a) should I store or handle hazardous
p
shall not employ any person in any manner so as to become subject to the material. Additionally, should I use equipment or devices which emit hazardous
air contaminants as defined b the Ba Area Air
Worker's Compensation laws of California. If, after making this certificate of y Y Quality Management District I
will maintain compliance with the Cupertino Municipal Cod hapter 9.12 and
exemption, I become subject to the Worker's Compensation provisions of the the Health & Safety Code ':o, 25505, 2553
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, andexpenses 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.
Licensed
Signature Date 10/19/2018 Professional