B-2019-0610 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0610
10568 JOHANSEN DR CUPERTINO,CA 95014-3507(375 36 017) C D ALL ROOFING
SAN JOSE,CA 95127
OWNER'S NAME: DATE ISSUED:04/10/2019
OWNER'S PHONE: PHONE NO:(408)898-6605
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 Lic.#1003820
Contractor C D ALL ROOFING Date 05/31/2019 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 following two declarations: RE-ROOF;TEAR-OFF;INSTALL COMP SHINGLES-(24 SQ)
1. I have and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the
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:$9500.00
APPLICANT CERTIFICATION
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 Number: Occupancy Type:
375
and state laws relating to building construction,and hereby authorize 375 36 017
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 nsd wild.., o ly th all non-point
9
Date:04/10/2019
OWNE UILDER 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 roe installed without first obtaining an inspection,I agree to r ove all
I hereby affirm under penalty of perjury one of the following three declarations: ALL R OF COVERINGS TO BEC
1. I have and will maintain a Certificate of Consent to self-insure for Worker's LASS"A"OR BETTER
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. 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
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 this permit is issued,I Health&Safety Code,Section 25532(a)should I store or handle hazardous
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 by the Bay Area Air Quality Management D'is'trict I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance with the Cupertino Municipal CodeXfiapter 9.12 an
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a 60hstruction IQ^nding'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.
Licensed
Signature Date 4/10/19 Professional