15040207CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 7799 LILAC WAY
CONTRACTOR: LINDY ROOFING
PERMIT NO: 15040207
COMPANY
OWNER'S NAME: ROBINSON KENNETH W AND LINDA
476 W TAYLOR ST
DATE ISSUED: 04/28/2015
OWNER'S PHONE: 4087592864
SAN JOSE, CA 95110
PHONE NO: (408)286-9990
❑ LICENSED CONTRACTOR'S DECLARATION
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BUILDING PERMIT INFO: BLDG ELECT PLUMB
License Class Lic.##
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MECH RESIDENTIAL COMMERCIAL
Contractor Date
JOB DESCRIPTION- REMOVING ONE LAYER OF WOOD SHINGLES AND
I hereby affirm that I am licensed under the provisions of Chapter 9
INSTALLING
A DIMENSIONAL COMPOSITION ROOF WITH OSB SHEATING,
(commencing with Section 7000) of Division 3 of the Business & Professions
FLASHINGS, OHAGINS 28 SQRS
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
Sq. Ft Floor Area: 0
Valuation: $16000
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
permit is issued.
APN Number: 35904011 00
Occupancy Type:
APPLICANT CERTIFICATION
I certify that I have read this application and state that the above information is
PERMIT EXPIRES IF WORK IS NOT STARTED
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
WITHIlV 180 DAYS OF PERMIT ISSUANCE OR
upon the above mentioned property for inspection purposes. (We) agree to save
180 DAYS FROM LAST CALLED INSPECTION.
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
Issued by: Date:
with all non-point source regulations per the Cupertino Municipal Code, Section
9 18.
Signature Date
RE-ROOFS:
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
inspection.
ElOWNER-BUILDERDECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of
Signature of Applicant: Date:
the following two reasons:
I, as owner of the property, or my employees with wages as their sole compensation,
ALL ROOF COVERINGS TO BE CLASS "A" OR BETTER
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
I, as owner of the property, am exclusively contracting with licensed contractors to
HAZARDOUS MATERIALS DISCLOSURE
construct the project (Sec.7044, Business & Professions Code).
I have read the hazardous materials requirements under Chapter 6.95 of the
I hereby affirm under penalty of perjury one of the following three
California Health & Safety Code, Sections 25505, 25533, and 25534. I will
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's
Health & Safety Code, Section 25532(a) should I store or handle hazardous
material. Additionally, should I use equipment or devices which emit hazardous
Compensation, as provided for by Section 3700 of the Labor Code, for the
air contaminants as defined by the Bay Area Air Quality Management District I
performance of the work for which this permit is issued.
will maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and
I have and will maintain Worker's Compensation Insurance, as provided for by
the Health & Safety Code, Sections 25505, 25533, and 25534.
Section 3700 of the Labor Code, for the performance of the work for which this
permit is issued.
Owner or authorized agent: Date:
I 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
Compensation laws of California. If, after making this certificate of exemption, I
CONSTRUCTION LENDING AGENCY
become subject to the Worker's Compensation provisions of the Labor Code, I must
I hereby affirm that there is a construction lending agency for the performance of
forthwith comply with such provisions or this permit shall be deemed revoked.
work's for which this permit is issued (Sec. 3097, Civ C.)
Lender's Name
Lender's Address
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
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 Ci tyof Cu ertino against liabilities, judgments,
ARCHITECT'S DECLARATION
costs, and expenses which may accrue against said City in consequence of the
I understand my plans shall be used as public records.
granting of this permit. Additionally, the applicant understands and will comply
with all non-point source regulations per the Cupertino Municipal Code, Section
Licensed Professional
918.
Signature Date
7 7-1 BON M0_ NOXIDE ALARMS
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