B-2019-0910 CITY OF CUPEW11
BUILDING PET T y
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CONTRACT OR: PERAMIT -2019-0910
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BUILDING PERMIT INFO:
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tSection1-00 )ovis 3 f-the B Usines, Professions Code n��that m
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'JOB DESCRUP140N:
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hereby:affirm under ; pejT one of the followinig two declarations: ,.(283
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'Date:05,123,12-019
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HAZAR09MUS MAI ERIALaDjagLOSURE
Perm _ /i i �� read the az daus materials requirements u Chapter 6.95 the
.`g-. 1 cerci' -z in,i ts,.p"er�E.rzance'Eo the w€ r which=£ Fiume",^s.Srrwl�+F.: � 4 .� .. .Y `
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Labor Code, must f�hw th comnly �t +3 Ad h' z r issi s r this perms t t K
„ eeined re-�. K mill t t np -with theCu ' . c� . and
the Health&Safety od
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jou.costs,and expenses wrhich may accrue againnsi said Q se `s Name
con, R. Additionally,the applicant undert �th '
d comply with all o pon iiuy¢e r� .# ons per h CupertinoMunicipal
Lender's Address
Code, e tion 9.18.
_qunderstand y Arps sha be usAd as public record
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CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-0910
20432 SILVERADO AVE STE 3 CUPERTINO,CA 95014-4454(369 52 003)120432 WINTER ROOFING
SILVERADO AVE STE 2 CUPERTINO,CA 95014-4454(369 52 002)20432 INC
SILVERADO AVE STE 1 CUPERTINO,CA 95014-4454(369 52 00 1) MORGAN HILL,CA
95037
OWNER'S NAME: DATE ISSUED:05/23/2019
OWNER'S PHONE: PHONE NO:(408)363-8052
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.#752097
Contractor WINTER ROOFING INC Date 07/31/2020 X BLDG —ELECT —PLUMB
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing MECH_RESIDENTIAL X 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 1/2"OSB; INSTALL COMP SINGLES
I hereby affirm under penalty of perjury one of the following two declarations: -(28 SQ)
1. I have and will maintain a certificate of consent to self-insure for Worker's 20432 SILVERADO AVE STE 1 CUPERTINO,CA 95014-4454(369 52
Compensation,as provided for by Section 3700 of the Labor Code,for the 001 STE 1)
performance of the work for which this permit is issued. 20432 SILVERADO AVE STE 2 CUPERTINO,CA 95014-4454(3 69 52
I have and will maintain Worker's Compensation Insurance,as provided for by 002 STE 2)
Section 3700 of the Labor Code,for the performance of the work for which this 20432 SILVERADO AVE STE 3 CUPERTINO,CA 95014-4454(369 52
permit is issued. 003 STE 3)
APPLICANT CERTIFICATION Sq.Ft Floor Area: Valuation:$10800.00
1 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
and state laws relating to building construction,and hereby authorize APN Number: Occupancy Type:
representatives of this city to enter upon the above mentioned property for 369 52 001
inspection purposes. (We)agree to save indemnify and keep harmless the
City of Cupertino against liabilities,judgments,costs,and expenses which
may accrue against said City in consequence of the granting of this permit. PERMIT EXPIRES IF WORK IS NOT STARTED
Additionally,the applicant understands and will comply with all non-point
source regulations per the Cupertino Municipal Code,Section 9.18. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
Signature ` - Date 05/23/2019
Issued by:Jasmine Archbold
OWNER-BUILDER DECLARATION Date:05/23/2019
I hereby affirm that I am exempt from the Contractor's License Law for one of the
following two reasons: RE-ROOFS:
1. I,as owner of the property,or my employees with wages as their sole All roofs shall be inspected prior to any roofing material being installed.If a roof is
compensation,will do the work,and the structure is not intended or offered for installed without first obtaining an inspection,I agree to remove all new materials for
sale(Sec.7044,Business&Professions Code)
I hereby affirm under penalty of perjury one of the following three declarations: Date:05/23/2019
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 ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
performance of the work for which this permit is issued.
2. I have and will maintain Worker's Compensation Insurance,as provided for by HAZARDOUS MATERIALS DISCLOSURE
Section 3700 of the Labor Code,for the performance of the work for which this I have read the hazardous materials requirements under Chapter 6.95 of the
permit is issued. California Health&Safety Code,Sections 25505,25533,and 25534. I will
3. I certify that in the performance of the work for which this permit is issued,I maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
shall not employ any person in any manner so as to become subject to the Health&Safety Code,Section 25532(a)should I store or handle hazardous
Worker's Compensation laws of California. If,after making this certificate of material. Additionally,should I use equipment or devices which emit hazardous
exemption,I become subject to the Worker's Compensation provisions of the air contaminants as defined by the Bay Area Air Quality Management D. trict I
Labor Code,I must forthwith comply with such provisions or this permit shall will maintain compliance with the Cupertino Municipal Code,Chapt 9.12 and
be deemed revoked. the Health&Safety Code,Sections 2
APPLICANT CERTIFICATION Owner or authorized agent:
I certify that I have read this application and state that the above information is Date:05/23/2019
correct.I agree to comply with all city and county ordinances and state laws CONSTRUCkLLEN1 ING AGENCY
relating to building construction,and hereby authorize representatives of this city I hereby affirm that there is a construction lending agency for the performance
to enter upon the above mentioned property for inspection purposes. (We)agree of work's for which this permit is issued(Sec.3097,Civ C.)
to save indemnify and keep harmless the City of Cupertino against liabilities, Lender's Name
judgments,costs,and expenses which may accrue against said City in
consequence of the granting of this permit. Additionally,the applicant understands Lender's Address
and will comply with all non-point source regulations per the Cupertino Municipal
Code,Section 9.18. ARCHITECT'S DECLARATION
I understand my plans shall be used as public records.
Signature Date 05/23/2019
Licensed