12110012 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21588 ROSARIO AVE CON•IRACI'OR:WESTSHORE ROOFING PERMIT NO: 12110012
INC
OWNER'S NAME: CHEN TEYAO AND HUI M 2245-A FOR'T'UNE DR DA'Z'E ISSUED: 1110212012
OWNER'S PHONE: 4087253668 SAN JOSE,CA 95131 PHONE NO:(408)694-0060
❑ LICENSED CO\fRACI'OR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG 1- ELECT r PLUMB r
License Class Lic.b
- DIFCIi [ RESIDENTIAL "' COMMERCIAL J
Contractor Dale
T hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE ESI$TING SHAKE ROOF&INSTALL STONE
(commencing with Section 7000)of Division 3 of the Business&Professions COAT
IiD
Code and that my license is in full force and effect. STEEL ROOF SYSTEM-33 SQ
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent 10 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 die work for which this Sq.Ft Floor Area:0 Valumion:$23800
permit is issued.
,%PPI.IC,\N"1'CER'I'IF'IC 'I'1ON APN Number:35619018.00 Occapancy Type:
I cenify 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,
costs,and expenses which may accrue against said City in consequence ofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulatimos per the Cupertino Municipal Code,Section
180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Dale Issued by: Date:
❑ OWNER-BUILDER DECLARATION
RE-ROOFS:
hereby affirm that I am eyempt from the Contractor's License Law for one of All roofs shall be inspected prior to;my rooting material being installed.If a roof is
the folluw'ing 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&Professions Code) Signature of Applimm: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALI,ROOF COVERINGS T'O BE CLASS"A"OR BETTER
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 UALARDOUS MATERLx LS 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 Health S Safety Code,Sections 25505,25533,and 25534. 1 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 Health S
Section 3700 of the Labor Code,for the performance of the work for which this Safely Code,Section 25532(x)should 1 store or handle hazardous material.
Additiormlivshould 1 use equipment or devices which emit hazardous air
permit is issued. contaminants as defined by the Bn% 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 Health&Safety Code,Sections 25505,25533,and 25534.
Compensation laws ofCalifomia. If,after making this cenifcaic 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. Dale:
APPLICANT CERTIFICATION CONSfR11CfION LENIIING AGENCY
I cenify that I have read this application and state that the above information is I hereby affirm that there is it construction lending agency for the performance of work's
cored.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 Cupertino against liabilities,judgments, Lender's Address
costs,and expenses which may accme against said Cit in consequence oldie
granting of this permit.Additionally,the applicant understands atmd will comply AROIIITEC•I"S DECLARATION
with all non-point source regulatims per the Cupertino Municipal Code,Section
9.18, 1 understand my plans shal I be used as public records.
Signature Date Licensed Professional