10040016 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10699 RANDY LN CONTRACTOR:WESTSHORE ROOFING PERMIT NO: 10040016
INC
2245-A FORTUNE DR DATE ISSUED:04/02/2010
PER'S NAME: ROVETTA ROBERT S AND CYNDRA A
SAN JOSE,CA 95131 PHONE NO:(408)694-0060
OWNER'S PHONE: 4082559351
❑ LICENSED CONTRACTOS DECLARATION BUILDING PERMIT INFO: BLDG ELECT PLUMB
R'
License Class Lic.# MECH r- RESIDENTIAL I— COMMERCIAL
Contractor Date
JOB DESCRIPTION:REMOVE COMP AND INSTALL COMP ROOF
I hereby affirm that I am licensed under the provisions of Chapter 9
(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 Valuation:$16288
performance of the work for which this permit is issued. Sq.Ft Floor Area:0
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 APN Number:31602043.00 Occupancy Type:
permit is issued.
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 WITHIN 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We)agree to save
indemnify and keep harmless the City of Cupertino against liabilities,judgments, 180 DAYS FROM LAST CALLED INSPECTION.
costs,and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally,the applicant understands and will comply Date:
with all non-point source regulations per the Cupertino Municipal Code,Section Issued by:
9.18.
rure
Date
RE-ROOFS:
❑ OWNER-BUILDER DECLARATION All roofs shall be inspected prior to any roofing material being installed.If a roof is
installed without first obtaining an inspection,I agree to remove all new materials for
I hereby affirm that I am exempt from the Contractor's License Law for one of inspection.
the following two reasons: Date:
I,as owner of the property,or my employees with wages as their sole compensation, Signature of Applicant:
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). HAZARDOUS MATERIALS DISCLOSURE
I hereby affirm under penalty of perjury one of the following three
declarations: I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain a Certificate of Consent to self-insure for Worker's California Health&Safety Code,Sections 25505,25533,and 25534. I will maintain
Compensation,as provided for by Section 3700 of the Labor Code,for the Safety complianc
ewith ton the Cupertino
5532(a)should I Municistore al de ,Chapter.12 a d the Health&
performance of the work for which this permit is issued. Additionally,should I use equipment or devices which emit hazardous air
I have and will maintain Worker's Compensation Insurance,as provided for this
contaminants as defined by the Bay Area Air Quality Management District I will
Section 3700 of the Labor Code,for the performance of the work for which this maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
permit is issued. Health&Safety Code,Sections 25505,25533,and 25534.
1 certify that in the performance of the work for which this permit is issued,I shall
not employ any person in any manner so as to become subject to the Worker's Owner or authorized agent: Date:
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
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that there is a construction lending agency for the performance of work's
APPLICANT CERTIFICATION for which this permit is issued(Sec.3097,Civ C.)
I certify that I have read this application and state that the above information is Lender's Name
correct.I agree to comply with all city and county ordinances and state laws relating
to'ilding construction,and hereby authorize representatives of this city to enter Lender's Address
he above mentioned property for inspection purposes.(We)agree to save
ii,,..,.nnify and keep harmless the City of Cupertino against liabilities,judgments, ARCHITECT'S DECLARATION
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply I understand my plans shall be used as public records.
with all non-point source regulations per the Cupertino Municipal Code,Section Licensed Professional
9.18.
Signature Date
I'r ;10030006
O BUILDING PERM STRUCTION PERMIT N
p
OF CUP
pERTIN pNIRACTOVL-.D coN ISSUED:04108120/0
ATE
CITY uric PHONE NO.(409)942-8.100
LIAR DR
V"BW CT 690 GVIB 95035 PLUMB
ppREss� 10400 RIDGE
A MILpI'IAS,CA � ELECT MERCIP.L
BUILDING INFO•. BLDG COM
APPLE 114C G'PERMIT TIAL
R S NAME: MECx RESIDEI`1 CE ON TNS IST
gUILDIN
408862439"1 TION FT OFFICE SPA
pWNER S pHpNE SED CONTRACTpIt S CLA IPTI01`l T 1 MO RUC'fRUAI
LICEN pG
N
10B D OF 2 STORY BL
ID
pate FLOOR
r Chapter 9
License Class S,professions
the provision us► ess
Contractor under 3 of o the g
Contra a ►rm that I am licensed vision
X000)of
1). effect. tion:$120000
1 hereby with Section full force and two declarations:
valuation.
(commencing t my license is in ury one°f the following worker's
d tha ° insure for the
Code an erj self- aucy rypc'
under penalty°f P e tot
of con of the Labor Cod Ft Floor Area: pccuP
I hereby affirm a cedificate Sq.
d will maintain b Section 3�0 issued_ provided for by L
1 have an PTO
for Y this pemut is ce, this p46.AP
which lnsuran ork for which Number;31606 5,r AR•r�,i D
Compensation,as P work for Compensation ce of the APN OT R
performance of the workers perform O,,1Z 15 N NCV1 O
,Hill maintain Code,for the p S IF SOW
IT ISSU A
(have and 00 oftheLabor ,,� E CTI
NT CERTIFICATION ve information is IT EXpI YS 1 p D IN5pE O
Section 3 issued. at
the abo and state laws relating pE D
permit is ki fill A d state to enter wi IN lg0 AST CALLS
lication an ordinances of this olty ROM L
have read this app and county tatives to save
that 1 h fO comply wa h all ct authori ecti ori p en oses. (we)agree ments, Igo DAY S
1 certify be' u'3' liabilities,Judg
1 agree ction>an erty for insp amst ce of the
coffee'. ertin°ag . consequen
construction, City of Cup City ds and will comPW
ouponithe above mentharmless the Section by:
and keep a against said derstan al Code, issued
nify eases which may a al y the aPplican rtino Munic►p
indem e Cup If a roof
and eXP it. Oil Pei the RE RpOFS: eing installed)materials
costs, ►s perm legal ions P to any roof�teeial em0ve all ne
ranting of til so cc reg �� to
with all nowpp1nt s n pate
9 18 i -...x All roofs w aXbill-
t f rst obta n ng an inspection,l ag
Date-.
S 're R pECLARATIpN of installed
icense Law for one inspection.
ILDE s L licant'• �OR BETTER
pwNER gU front the Contractor of APP A'
�their sole compensation, Signature
44, CpVER GS TO BE CLASS
m exempt fr Sec 10 IN
affirm that l a employees with wages sale( ppF
hereby two reasons: or offered for A
DISCLOSUR
the following property,or mY of intended TERIALS 6.9
Owner of the prop e structure is n licensed contractors to HAZARDOUS NIA er Chapter
0
1, work,and the ct. with ents and d 25534• I N
will do the Code) contra require 25533,a
am exclusively Code)' terials req s 25505 9.I2 and
the
Business&ptofess'►°OpertY &Professions rdous C Section
1
Business
owner of the eco( 44>$us►ness three aza ode,handle
azardou rd ate
e l► Safety Code,q►►icipal C
Sec 10 of perjury one of the following I have r is health& handle
it haza ons
Cupertino M I store or 'Which em
ct the prOJ for worker's California with the shronnent or devices Nil manage
nt U�
construct under pcoal" insure co►nPl►ance 25532(a) uaxi C d P
self for the Section Air Q Code,Cha ter 9.
affirm Consent t the Labor Code, Safety Code, should I us b q ipgaY Area
hereby Certificate of 3100 as defined y
ith the Cupertino Mun►c►P 5
sinal a b Section ed for by cddit O nalnts 25505,25533,an
d2 5 '
doaara a v�yll m ed tot Y it is issued as provid lianc
have ro'it this pe"n Insurance, Nbich this comp Sections
nsation,asp which e work for malntai& afety °
Comp, ance of the work for ,s Compensation He ►t
perform Worker tilt performance°f I shall nt: pate:
1 have and will Mal de Code,for it is issued,
abor this Pe o the worker's Win r G AGENCY
3 00 of the l which NV)
Section work for e subject of eXeruption,l CONST CTION LE y o P
issued. nice of the t0 become must enc for the per
P it is Code, m
erm t that in the perform any
manner of as ming tilts cern f the Labor lending agency
i cert is If,after
there is a construction
not employ any person rov.t sha of cd revoked 1,Civ C•)
la**'s of California. Orupensation P it shall be deem affirm that ed(Sec.309
Compensation the worker's C or this pet"
1 hereby this pern►it is issu
e subject to rovisions LQ ser S Name
becom comply*vith such P pN
T CERTIFI ,,,t the above information is
fotth*�ith s relating ,S pECL?►RATION
AppLiCA1v d state chat til and state law Lenders Address
of this city 1O enter AItCIIITEC'C
d this application an ordinances to save
have res d county public records.
that 1 ha 1 with all city tanhOr1zc reptesentoses (we)agree menu° used as p
I certify ree to comp Y d hereby au ection Pu'� liabilities,Ill fans shall be
correct.l agconstruction,an P, of for insp ertino namstconsequence°f the d MY p
w•;Ading ed p of Cup in ill comply
l understan
to c above menun less the C►tye against said city
and, Section
IL and keep m y accru a t o no uuicipal Code, professions►
in4�.:�mfi which Licensed
A expenses ddionally,the helCuPe1� M
costs,an permit.e d e lations p
grith all n oir�t soaF /'��
I �`--/ pat
9.19.