13080033CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1283 POPPY WAY
CONTRACTOR: WESTERN ROOFING
PERMIT NO: 13080033
SYSTEMS
OWNER'S NAME:
License CIASS LIc.#
BUILDING PERMIT INFO: BLDG i ELECT f— PLUMB
,
ContractorDate
i"
MECH RESIDENTIAL ' COMMERCIAL
I hereby affirm that 1 am licensed under the provisions of Chapter 9
(commencing with Section 7000) of Division 3 Business
JOB DESCRIPTION: TF,AROPF WOOD SHAKE AND INSTALL METAL SI IAKI:
PER ER
of the & Professions
Code and that my license is in full force and effect.
3098-28SQ
I hereby affirm under penalty of perjury one of the following two 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
Section 3700 of the Labor Code, for the performance of the work for which this
Sq. Ft Floor Area: 0
permit is issued.
Valuation: $15500
APPLICANT CER'T'IFICATION
I certify that I have read this application and state that the above information is
APN Number: 36618020.00 Occupancy'I'ype:
correct. I agree to comply with all city and county 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 save
indemnity and keep harmless the City of Cupertino against liabilities, judgments,
PERMIT EXPIRES IF WORK IS NOT STARTED
costs, and expenses which may accrue against said City in consequence of the
granting this Additionally,
WITHIN 180 DAYS OF PERMIT ISSUANCE
permit. the applicant understands and will comply
OR
with all non -point source regulations per the Cupertino Municipal Code, Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date
Issued by: Date:
El OWNER -BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of RE -ROOFS:
the following two reasons: All roofs shall be inspected prior to any roofing material being installed.
1, as owner of the property, or my employees with wages as their sole compensation, Installed
If a roof is
without first obtaining an inspection, I agree to remove all new materials for
will do the work, and the structure is not intended or offered for sale (Sec.7044, Inspection.
Business & Professions Code) Signature of Applicant: Date:
1, as owner of the property, am exclusively contracting with licensed contractors to
construct the project (Sec.7044, Business & Professions Code).
1 hereby affirm under penalty of perjury one of the following
ALT, ROOF COVERINGS TO BE CLASS "A" OR BET`FER
three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS MATERIALS DISCLOSURE
Compensation, as provided for by Section 3700 of the Labor Code, for the 1
performance ofthe work for which this is issued.
have read the hazardous materials requirements under Chapter 6.95 of the
permit California
I have and will maintain Worker's Compensation Insurance, as provided for by compliance
Health & Safety Code, Sections 25505, 25533, and 25534. 1 will maintain
with the Cupertino Municipal Code, Chapter 9.12 and the Health &
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.
permit is issued. Additionally, should I use equipment or devices which emit hazardous air
I certify that in the performance of the work for which this permit is issued, I shall contaminants as defined by the Bay Area Air Quality Management District 1 will
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 Health & Safety Code, Sections 25505, 25533, 25534.
Compensation laws of California. If, after making this certificate of exemption, I
and
become subject to the Worker's Compensation provisions of the Labor Code, 1 must Owner or authorized agent:
forthwith Comply with such provisions or this permit shall be deemed revoked.
Date:
APPLICANT CF,RTIFICATION
CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is I
correct. I agree to comply with all city and county ordinances and laws
hereby affirm that there is a construction lending agency for the performance of work's
state relating for which this permit 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
indemnity 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
with all non -point source regulations per the Cupertino Municipal Code, Section
ARCIIITECT'S DECLARATION
9.18.
1 understand
my plans shall be used as public records.
Signature Date Licensed Professional