12090137 CITY OF CUPERTINO BUILDING PERMIT
BUILDINGADDRESS: 10230 BONNY DR CON'TRACT'OR:T.D ROOFING PERNUT NO: 12090137
OWNER'SNAME: STYLES-TIALLIANICEM 675TULLYRD DATE ISSUED:09/15/2012
OW'NER'S PUONF-: 4082032547 SANJOSE.CA 95111 PHONE NO:(408)8924872
❑ LICENSED CON'TRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG C ELECT❑ PLUMB r
License Class Lic.q
M ECII r RESIDENTIAL "' COMMERCIAL i
Contractor Date
hereby affirm that l tan licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE SHAKE INSTALL OSIS 15#FELT AND
(commencing with Section 7000)of Division 3 of the Rosiness& Professions PRESIDENTIAL
Code and that my license is in full force and effect. SHAKE 25 SO
hereby affirm under penalty of perjury one of the following two 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
Section 3700 of the Labor Code,for the performnce of die work for which this Sq.Ft Floor Aren:0 Valuation:S 11000
permit is issued.
,APPLICANT CERTIFICA'T'ION APS Number:35911043.00 OccupancyType:
I certify that I have read this application and state that the above information is
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 to save PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep harmless the City of Cupertino against liabilities,judgments, WITHIN Igo DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant uidcrstands 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: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any rooting material berg installed.Ira roof is
the following two reasons: installed without first obtaining an inspection,I agree to remove all neve 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&Professions Code) Signature of Applicant: Date:
1,as owner of the property,am exclusively contracting with licensed contractors to
consumer the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGSTO RE CLASS"A"OR RE,iTER
I hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent m self-insure for Worker's ILA-l..ARIlO11S alAl'FRIAIS 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 llealth&Safety Code.Sections 2.5505,25533,and 25534. I will 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 llealth&
Safety Code.Section 25532(a)should I store or handle hazardous material.
Section 3700 of the Labor Code,Ibr the performnce of the work for which this ,Additionally,should I use equipment or devices which emit huzurdous air
permit is issued. contaminants as defined by the Bay Area Air Quality Management District I 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 llealth&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 rhe Labor Code,I must Owner or authorized agent:
Forthwith comply with such provisions or this permit shall be deemed revoked. Date:
CONSTRIICPION LENDING AGENCY
,APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I 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 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 ARCHI'T'ECT"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional