10100156 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 1170 STAFFORD DR CON-RACTOR:LOS GATOS ROOFING PERMIT NO: 10100156
OWNER'S NAME: HEBSON ROBERT T AND OPAL B TRU
P O BOX 1726 DATE ISSUED: 10/21/2010
1ER'S PHONE: 4082553753
LOS GATOS,CA 95031 PHONE NO:(408)298-9399
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG[— ELECT r— PLUMB
License Class Lic.# MECH r— RESIDENTIAL r— COMMERCIAL
Contractor Date
JOB DESCRIPTION: TEAR OFF EXISTING PERMA TEC ROOFING. USE
I hereby affirm that I am licensed under the provisions of Chapter 9 EXIS PING
(commencing with Section 7000)of Division 3 of the Business&Professions pLYY'OOD. INSTALL ROOFERS SELECT FELTAND
Code and that my license is in full force and effect. pREA IDENTIAL TL SHINGLES BY CERTAINTEED.
I 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 performance of the work for which this Valuation:$8877
permit is issued. Sq.Ft Floor Area:0
APPLICANT CERTIFICATION arc Occu Type:
I certify that I have read this application and state that the above information is APT Number:36207002.00 Occupancy YP
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
indemnify 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 of this permit. Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature
Date Isst ed by: Date:
Li 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 -oofs shall be inspected prior to any roofing material being installed.If a roof is
I,as owner of the property,or my employees with wages as their sole compensation, instilled 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, insl ection.
Business&Professions Code) Sig nature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code).
ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I 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 HAZARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I h the read the hazardous materials requirements under Chapter 6.95 of the
Ca Jfornia Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,as provided for by con npliance 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 Sa-ety 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 I will
not employ any person in any manner so as to become subject to the Worker's me intain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I
He alth&Safety Code,Sections 25505,25533,and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must 01 vner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
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 I I ereby affirm that there is a construction lending agency for the performance of work's
to building construction,and hereby authorize representatives of this city to enter fo•which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
tnify and keep harmless the City of Cupertino against liabilities,judgments, Lo mder's Address
,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 ARCHITECT'S DECLARATION
9.18.
11 mderstand my plans shall be used as public records.
Signature Date
L censed Professional