12080022CITY OF CUPERTINO BUILDING PERMIT
RUILDING ADDRESS: 22706 ROYAL OAK WAN'
CO,N'IRAM'011: PETERSEN-DEAN INC
PERMITNO: 12080022
OWNER'S NAME: KANDACE KLEMBA
7980 EN ERPRISE DR
DA'Z'E ISSUED: 08/062012
OWNER'S PHONE: 4087770332
NEWARK. CA 94560
PHONENO:(510)494-9982
❑ LICENSED CON fRACI'OR'S DECLARATION
r r r
BUILDING PERMIT INFO: BLDG ELECT PLUNIB
License Class Lie.N
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Mecn REsu3eNT•L\L COMMERCIAL
Contractor Date
1 herchp affirm that lain licensed under the provisions of Chapter 9
JOB DESCRIPTION: REMOVE Sl IAK17 ROOF INSTALL PRESIDI?NTIAL TL
(commencing with Section 7000) of Division 3 of the Business S Professions
SHINGLES
OVI7R 30N Fmj AND PLYWOOD 9 SO
Code and that nuc license is in full force and effect.
I hereby affirm wider penalty of perjury one of the following bio declarations:
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.
I have and will maintain Worker's Compensation Insurance, as provided for by
Sq. Ft Fluor Area: 0
Valuation: $5000
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
,U ,N Number: 34232127.00 Occupancy Type:
.\I'PI,IC.\\I'CIiR'I'I FIG\'PION
I certify that I have read this application and state that the above information is
correct. 1 agree to comply with all city and county ordinances and state laws relating
to building construction, mid 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
andexp keep against liabilities,judgments,
harmless the City ol'Cupagainst
iosts,a
which
costs, and expenses which may accrue against said City in consequence of the
a]i said
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally, the applicant❑nderstandsand will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER -BUILDER DECLARATION
Iib: ROOFS:
1 hereby affirm that I am exempt front the Contractor's License Lam% for one of
All roofs shall be inspected prior to tory roofing material being installed If a roof is
the following ten reasons:
installed without first obtaining an inspection, I agree to remove all nese materials for
1, as owner of the property, or m)employee's with !Pages as their sole compensation,
inspection.
will do the work, and the structure is not Intended or offered for sale (Sec.7044.
Business 8 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 S Professions Code).
ALL ROOF CO\'IiRINCS'I'O BE CLASS ".\" OR REITER
hereby affirm under penalty of perjury one of the fullmving three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
HAZARDOUS NIATERIALS 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 I Iealth S Safety' Cade. Sections 25505.25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with (lie Cupertino dlunicipal Cade. Chapter 9.12 and the Ilealth S
Section 3700 of the Labor Code, for the performance of the stork 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 Ray Area Air Quality Management District I will
I certify that in the performance of the work forswhich this permit is issued 1 shall
maintain compliance with the Cupertinu Municipal Code. Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
I Ienith S Safety Code. Sections 25505, 25533. and 25534.
Compensation laws of California. 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 he deenwd revoked.
(late:
CONSTRUCTION LENDING AGENCY
\I'I'LIC.\\ I' CI';R'1'IPIG\'I'If1N
1 certify that I have read this application and state that the above information is
1 hereby affirm that there is a construction lending agency for the performance of smrk's
correct. 1 agree to comply with all city and county ordinances and state laws 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
indemnify and keep harmless the City of Cupertinoagainst liabilitiesJudgments,
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
.\ItCI I1'I'P:CI"S DI?CLARA'r10N
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 Dale
Licensed Professional