12110060CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22334 SANTA PAULA AVE
CONTRA(7TOR: WES'I'SIiORE ROOFING
PERMIT NO: 12110060
INC
OWNER'S NAME: CALAFIORE THOMAS F AND FLORENC
2245 -A FORTUNE DR
DA'Z'E ISSUED: 11/122012
OWNER'S PI ZONE: 4087251557
SAN.IOSE -CA 95131
PRONE NO: (408)694.1)060
❑ - LICENSED CONTRACI'OR'S DECLARATION
r r IJ
BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic. t!
r ❑
DI F.CII RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that I am licensed under the provisions of Chapter 9
JOB DESCRIPTION: TEAR OFF 2 LAYERS COMP. INSTALL LIFETUIE COMP
(commencing with Section 7000) of Division 3 of the Business S Professions
ROOF
SYSTEM OV17R OSB DECKING. 16 SOFT
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the following bro declarations:
1 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
'
Sq. Ft Flour Area: 0
Valuation: $7900
Section 3700 of the Labor Code, for the perfomtance of the work for which this
permit is issued.
APN Number: 35705044.00 Occupancy Type:
APPI.ICANTCF,R'1'11 >ICATI0N
I certify that I have read this application and state that the above information is
correct. I agree to comply with all city and comity ordinances and state laws relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify. and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this pe:mit.' Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Issued by: Dale:
Signature Date
❑ OWNER- RUILDER DECLARATION
•
RE ROOFS:
hereby affirm that I am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material being installed. If a roof is'
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business R Professions Code)
Signature of Applicant: Dale:
I, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
ALL R0017 COVERINGS TO RE CLASS "A" OR BE' 'I I'ER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self- insure for Worker's
IIA7.ARDOIIS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Ilcalth S Safely Code, Sections 25505, 25533, and 25534. I wiR maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Health S
Section 3700 of the Labor Code, for the performance of the work for which this
Safety Code, Section 25532(a) should I store or handle hazardous material.
Additionally, should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Bay Area Air Quality Management District 1 will
I certify that in the performance of the work for which this permit is issued, I shall
maintain compliance with the Cupertino Municipal Code. Chapter 9.12 and the,
not employ any person in any manner so as to become subject to the Worker's
Ilcalth S Safety Coda Sections 25505, 25533, and 25534.
Compensation laws of Califomia. If, after making this certificate of exemption, I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked.
[late:
CONSI'RUCHON LENDING AGENCY '
\PPLICANT CER'T'IFICATION
I certify that I have read this application and state that the above information is
I hereby affirm than there is a construction lending agency for the performance of dork's
correct..) agree to comply with all city and county ordinances and state laws relating
for which this pemnit is issued (Sec. 3097, Civ C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
,
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
. \RCIII'1'F:Ct "S DF:CLARA'I'ION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
1 understand my plans shall be used as public records.
Signature Date
Licensed Professional