B-2019-1012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2019-1012
20803 ALVES DR CUPERTINO,CA 95014-1899(326 32 039) STATEWIDE ROOFING
INC
SAN JOSE,CA 95112
OWNER'S NAME: DATE ISSUED:06/07/2019
OWNER'S PHONE: PHONE NO:(408)286-7828
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class c-39 Lic.#803926
Contractor STATEWIDE ROOFING INC Date 02/29/2020 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:
INSTALL COMP SHINGLES-(260 SQ)
I hereby firm under penalty of perjury one of the following two declarations:
pensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued.
2. 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:$141095.00
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 32632039 A(Tenant Improvements)
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
Additionall
Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 6/7/19 Issued by:Haley McKee
Date:06/07/2019
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
sale(Sec.7044,Business&Professions Code)
2. I,as owner of the property,am exclusively contracting with licensed Signature of Applic
contractors to construct the project(Sec.7044,Business&Professions Code). Date:6/7/19
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. 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 certifythat 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
p p material. Additionally,should I use equipment or devices which emit hazardous
shall not employ any person in any manner so as to become subject to the air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California. If,after making this certificate of will maintain compliance
and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent:-
APPLICANT
gent:APPLICANT CERTIFICATION Date: 6/7/19
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 works 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. I understand my plans shall be used as public records.
Signature Date 6/7/19 Licensed
Professional