B-2018-0954 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0954
21630 OF
WAY CUPERTINO,CA 95014-4786(356 18 012) APACHE ROOFING
COMPANY
SAN JOSE,CA 95123
OWNER'S NAME: DATE ISSUED:06/05/2018
OWNER'S PHONE: PHONE NO:(408)858.9145
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C-39 Lic.4791198
Contractor APACH E ROOFING COMPANY Date 02/2812019 X BLDG_ELECT_PLUMB
1 herebyaffirm that I am licensed under the provisions of Chapter 9 _MECH X RESIDENTIAL_COMMERCIAL
a p p (commencing
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in fall force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL EAGLE HEAVY WEIGHT TILE-(28
1 hereby affirm under penalty of perjury one of the following two declarations: SQ)
"'arraft
have and will maintain a certificate of consent to self-insure for Worker's
ompensation,as provided for by Section 3700 of the Labor Code,for the
rformance of the work for which this permit is issued.
ave and will maintain Worker's Compensation Insurance,as provided for by
ction 3700 of the Labor Code,for the performance ofthe work for which this is issued. Sq.Ft Floor Area: Valuation:$16000.00
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 APN Number: Occupancy Type:
and state laws relating to building construction,and hereby authorize 356 18 012
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,costs,and expenses which PERMIT EXPIRES IF WORK IS NOT STARTED
may accrue against said City In consequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the applicant understands and will comply with all non-point
source -�-7cup
in uniclpal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 06/0512018 Issued by:Jasmine Archbold
Date:06/05/2018
OWNER- IL DER DE LARA
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
fallowing two reasons: All roofs shall be inspected prior to any roofing material being installed Bra roof is
r. I,as owner ofthe property,or my employees with wages as their sole irstodled without first obtainiug all
A"OR BETTER
r, 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 Ore work for which this permit is issued HAZARDOUS MATERIALS DISCLOSURE
z. I have and will maintain Worker's Compensation Insurance,as provided for by I have read the hazardous materials requirements under Chapter 6.95 of the
Section 3700 of the Labor Code,for the performance of the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.1 will
Permit is issued maintain compliance with the Cupertino Municipal Code,Chapter 9.12 and the
s, I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 25532(x)should I store m-handle hazardous
sholl not employ son in an manner so as to become subject to the material,Additionally,should I use equipment or devices which emit hazardous
p y any per y m 1 air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Clmpter 9.12 orad
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safety Codc,Sect' s 2 5,2 3,and 25534.
Labor Cade,l must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized agent: / _
APPLICANT CERTIFICATION Data:0 6/0 512 01 8
1 certify that I have read this application and state that the above Information Is UCTIO LBNDI .AGENCV
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there is a construction lending agency for the performance
relating to building construction,and hereby authorize representatives of this city of work's for which this permit is Issued(Sec.3097,Civ C.)
to enter upon the above mentioned property for inspection purposes. (We)agree Lender's Name
to save indemnify and keep harmless the City of Cupertino against liabilities,
judgments,costs,and expenses which may accrue against said City in Lender's Address
consequence of the granting of this permit.Additionally,the applicant understands
and will comply with all non-point source regulations per the Cupertino Municipal ARCHITECT'SDECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
SignatureLicensed
Date 06/0512018
Professional