BLD-2020-1176BUILDING PERMIT
CUPERTINO
CITY HALL
10300 Torre Avenue • Cupertino, CA 95014-3255
PHONE 408-777-3228
WWW.CUPERTINO.ORG
BUILDING ADDRESS: 21074 RED FIR CT Cupertino
APN: 359 05 057
PERMIT NO: BLD-2020-1 176
CONTRACTOR:
STATEWIDE ROOFING INC, 1615 S 7TH ST UNIT C SAN JOSE
CONTRACTOR PHONE:
4088359553
DATE ISSUED 8/3/2020 4:52:05 PM
ISSUED BY: JASMINE ARCHBOLD
VALUATION: $6159.09
JOB DESCRIPTION
HOA - CARPORT # 18 - RE -ROOF; TEAR -OFF TAR AND GRAVEL ; INSTALL 60 MIL PVC - (4.4 SQ)
CUPERTINO ROUNDTREE
LICENSED CONTRACTOR DECLARATION
9 (commencing with Section 7000) of Division 3 of the Business & Professions Code and that my license is in full
CONTRACTOR:
STATEWIDE
LICENSED
C39
LICENSED
803926
EXP
02/28/2022
I hereby
force
I hereby
ROOFING INC
CLASS:
ROOFING, C21 BUILDING
NO:
DATE:
affirm that I
and effect.
affirm under
I have and will
for which this permit
I have and will
I certify that in the
laws
with such provisions
MOVING%2C DEMOLITION
am licensed under the provisions of Chapter
penatiy of perjury one of the following
maintain a certificate of consent to self
is issued.
maintain Worker's Compensation Insurance,
performance of the work for which
of California. If, after making this certificate
or this permit shall be deemed
three declarations:
-insure for Worker's Compensation, as provided for by Section 3700 of the Labor Code, for the performance of the
work
as provided for by Section 3700 of the Labor Code, for the performance of the work for which this permit is
this permit is issued, I shall not employ any person in any manner so as to become subject to the Worker's
of exemption, I become subject to the Worker's Compensation provisions of the Labor Code, I must forthwith
revoked.
V
issued.
Compensation
comply
HAZARDOUS MATERIALS DISCLOSURE
Chapter 6.95 of the California Health & Safety Code, Sections 25505, 25533, and 25534. I will maintain compliance
I have read the hazardous materials requirements under
the Cupertino Municipal Code, Chapter 9.12 and the
V
with
equipment
Municipal
Health & Safety Code, Section 25532(a) should I store or handle hazardous material. Additionally, should I use
as defined by the Bay Area Air Quality Management District I will maintain compliance with the Cupertino
Sections 25505, 25533, and 25534.
or devices which emit hazardous air contaminants
Code, Chapter 9.12 and the Health & Safety Code,
EPA LEAD -SAFE DISCLOSURE
for this project.
Firm Certification No:
An EPA Lead -Safe Certified Renovator will be responsible
Firm Name:
No EPA Lead -Safe Certified Firm is required for this project.
Certified
v
CONSTRUCTION LENDING AGENCY
lending agency for the performance of the work which this permit is issued (Section 3097, Civil Code).
Lender's Address:
I hereby
Yes
affirm
under penalty of perjury that there is a construction
No
V
Lender's
Name:
APPLICATION CERTIFICATION
above information is correct. I agree to comply with all city and county ordinances and state laws relating to building
to enter upon the above mentioned property for inspection purposes. (We) agree to save indemnify and keep
costs, and expenses which may accrue against said City in consequence of the granting of this permit. Additionally,
source regulations per the Cupertino Municipal Code, Section 9.18.
I certify
construction,
harmless
the
Signature:
that I have read
and hereby
the City of
applicant understands
this application and state that the
authorize representatives of this city
Cupertino against liabilities, judgements,
and will comply with all non -point
days after its issuance, or if the work authorized on the site by such permit is suspended or abandoned for a period
of 365 days after the time the work is commenced.