12030126 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 883 S TANTAU AVE CONTRACTOR:KEVIN SULLIVAN P'ERMI'T NO: 12030126
ROOFING
OWNER'S NAME.: LIN PAN&LIHUI WANG 1696 VALLEYOAKS DR DATE, ISSUE,D:03R3R012
OWNER'S PHONE: 4089311339 GILROY.CA 95020 PHONE NO:(308)842-1057
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG F ELECT r PLUMB 17l
License Class Lie.q
hIECH - RESIDENTIAL - COMMERCIAL -
Contractor Date
I hereby affirm that 1 anilicensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE EXISTING ROOF. INSTALL 30LB FELT AND
(commencing with Section 7000)of Division 3 of the Business&Professions COMPOSITION SHINGLES
Code and that my license is in full force and effect
1 hereby affirm under penally of perjury one of the fallowing two declarations:
I have and will maintain a certificate of consent(o self-insure for Worker's
Compensation,as provided far 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.FI Floor Area:0 Valuation:$8500
Section 3700 of the Labor Code,for the performance of One work for which this
permit is issued.
APNNumher:.37538043.00 OccupancyType:
AI'PI:IC.\N'1'CP;R'rIFIGVI'ION
I certify that I have read this application and sone that the above information is
correct. I.agree to comply with all city and county ordinances and stale links relating
to building construction,and hereby authorize representatives of this city menter PERMIT EXPIRES IF WORK IS NOT STARTED
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs.mrd expenses which mayaccme against said City in consequence of die 180 DAYS FROM LAST CALLED INSPECTION.
granting of this permit. Additionally,the applica t understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. Issued by: Dale:
Signature Date
❑ ON'NISR-RIILIIER DECLARATION RE-ROOFS:
All roofs shall be inspected prior to any roofing material being installed.If a roof is
hereby affirm that I am exempt from the Contractor's License Law for one of installed without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspection.
1,as owner of the property,or my employees with wages as their sole compensation,
will do the work.and the structure is not intended or offered for sale(Sec.7044, Signmure of Applicant: Date:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). A LL ROOF COVERINGS TO RE CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: IIA%ARDOUS MATERIALS DISCLOSURE
I have and will maintain a Certificate ofConsem to self-insure for Worker's I have read the hazardous materials requirements under Chapter(S.95 of the
Compensation,as provided for by Section 3700 of the Labor Code,for the California llealth&SafelyCode.Sections 25505,25533,and 25534. 1 will maintain
performance of the work for which this permit is issued. compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
I'have and will maintain Worker's Compensation Insurance,as provided for by Safety Code Section'_5532(a)should I store or handle hazardous material.
Section 3700 of(belabor Code,for the performance of the work for which this Additionally,should I use equipment or devices which emil hazardous air
permit is issued. contaminants as defined M'the Bay Arca Air Qmdily Management District I will
maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
I certify that in the perlbnnance of One work for which this permit is issued,I shall Ilenlih&Safety Code,Sections 25505,25533,and 2.5534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. II;alter making(his certificate ofexemp(ion,I Owner or authorized agent:
become subject to the Worker's Compensation provisions of the Labor Code,I must Date:
forthwith comply with such provisions or this permi(shall he deemed revoked.
CONSTRUC'T'ION 1.F.NDING AGENCY
APPLICANT CERTIFICATION I hereby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state deal the above information is for which this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply With all city and county ordinances and state laws relating Lender's Name.
to building construction,mid hereby authorize representatives of this city to enter '
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Address
indemnify and keep harmless the City of Cupenino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply, ARCUITECI"S DECLARATION
With all non-point Source regulations per the Cupenino Municipal Code,Section I understannd my plans shall be used as public records.
9.18.
Licensed Professional
Signature Date