10080191 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 18680 NEWSOM AVE E2245-A
ACTOR:WESTSHORE ROOFING PERMIT NO:10080191
ORTUNE DR DATE ISSUED:08/26/2010
NER'S NAME: HSUEH-CHIEN SUN SAN JOSE,CA 95131 PHONE NO:(408)694-0060
l►rvNER'S PHONE: 4082552938
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB
License Class Lie.# MECH I— RESIDENTIAL r COMMERCIAL
Contractor Date
JOB D 3SCRIPTION:REMOVE EXISTING TAR&GRA VEL ROOF&INSTAL
I hereby affirm that I am licensed under the provisions of Chapter 9 FLINTL 4STIC SELF ADHERED MODIFIED ROOF SYSTEM
(commencing with Section 7000)of Division 3 of the Business&Professions
Code and that my license is in full force and effect.
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. Valuation:$9880
1 have and will maintain Worker's Compensation Insurance,as provided for by rAPNtN
7oor Area:0
Section 3700 of the Labor Code,for the performance of the work for which this
permit is issued. umber:37530003.00 Occupancy Type:
APPLICANT CERTIFICATION
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 PERMIT EXPIRES IF WORK IS NOT STARTED
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, WITHIN 1FROM LAST CALLED INSPECTION.costs,and expenses which may accrue against said City in consequence of the 1130 DAYS
granting of this permit. Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by: Date:
9.18.
�=~�ature Date
RE-ROOFS:
❑ OWNER-BUILDER ECLARATION All ro ifs shall be inspected prior to any roofing material being installed.If a roof is
D
I hereby affirm that I am exempt from the Contractor's License Law for one of install:d without first obtaining an inspection,I agree to remove all new materials for
the following two reasons: inspe<tion.
I,as owner of the property,or my employees with wages as their sole compensation, Date:
will do the work,and the structure is not intended or offered for sale(Sec.7044, Signa.ure of Applicant:
Business&Professions Code)
1,as owner of the property,am exclusively contracting with licensed contractors to ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
construct the project(Sec.7044,Business&Professions Code).
I hereby affirm under penalty of perjury one of the following three HAZARDOUS MATERIALS DISCLOSURE
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's I hay a read the hazardous dmaterials
sections 25505 requirements
25 33under
and25534.Chapter
95 of the
I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the compliance Calilornia Health Coe
with the Cupertino Municipal Code,Chapter 9.12 and the Health&
performance of the work for which this permit is issued. Safe y Code,Section 25532(a)should I store or handle hazardous material.
I have and will maintain Worker's Compensation Insurance,as provided for by Add tionally,should I use equipment or devices which emit hazardous air
Section 3700 of the Labor Code,for the performance of the work for which this cont iminants as defined by the Bay Area Air Quality Management District I will
permit is issued. maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
I certify that in the performance of the work for which this permit is issued,I shall
Hea th&Safety Code,Sections 25505,25533,and 25534.
not employ any person in any manner so as to become subject to the Worker's
Compensation laws of California. If,after making this certificate of exemption,I Owner or authorized agent: Date:
become subject to the Worker's Compensation provisions of the Labor Code,I must —
forthwith comply with such provisions or this permit shall be deemed revoked. CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION I he-eby affirm that there is a construction lending agency for the performance of work's
I certify that I have read this application and state that the above information is for vhich this permit is issued(Sec.3097,Civ C.)
correct.I agree to comply with all city and county ordinances and state laws relating Ler der's Name
to building construction,and hereby authorize representatives of this city to enter
the above mentioned property for inspection purposes.(We)agree to save Lender's Address
mify and keep harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the ARCHITECT'S DECLARATION
granting of this permit.Additionally,the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code,Section I uj iderstand my plans shall be used as public records.
9.18. Lir ensed Professional
Signature Date_