B-2018-1019 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1019
22421 WALNUT CIR S CUPERTINO,CA 95014-2741(357 03 044) M C ROOFING
SAN JOSE,CA 95127
OWNER'S NAME: DATE ISSUED:06/14/2018
OWNER'S PHONE: PHONE NO:(408)729-3436
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class CC=39 Lit.#Z3f$.@3 X BLDG_ELECT_PLUMB
Contractor M C ROOFING Date 06/30/2019 —
I hereby affirm that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL—COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Cade and that my
license is in full force and effect. JOB DESCRIPTION;
RE-ROOF;TEAR-OFF;INSTALL COMP-(30 SQ)
I hereby affirm under penalty of perjury one of the following two declarations:
t. 1 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
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. Sq.Ft Floor Area: Valuation:$17700.00
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 35703 044
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 com Iy with all non-point
source regulations p r th Cupertino Q e, with
9.113. 180 DAYS FROM LAST CALLED INSPECTION.
Si9natU / Date 06/1412018 Issued by:Jasmine Archbold
Date:06/14/2018
OWN R-BUI1 ECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for one of theRE-ROOFS:
following two reasons: All roofs shall be inspected prior to any roofing material being installed.If a roof is
r. 1,as owner of the property,or my employees with wages as their sole installed without first obtaining air,nspee-n,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for cation.
sae(Sec.7044,Business&Professions Cade)
z I,as owner of the property,am exclusively contracting with licensed Signature of Appliam
contractors to construct the project(Sce.7044,Business&Professions Cade). Date:06114/2019
I hereby affirm under penalty of perjury one of the following three declarations:
r. I have and will maintain a Certificate V Consent to self-insure for Worker's ALL ROOF COVERINGS TO BE CLASS"A"OR BETTER
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance fthe 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,too the performance at'the work for which this California Health&Safety Code,Sections 25505,25533,and 25534.I 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,l Health&Safety Cade,Section 25532(x)should I store or handle hazardous
shall not employ any person any manner
sas to become subject to the material.Additionally,should I rise equipment or devices which emit hazardous
air contaminants as defined by the Bay Area Air Quality Management District I
Worker's Compensation laws ofCalifornia,If,after making this certificate of will maintain compliance with the Cupertino Municipal Code,Cha ter 9.12 and
exemption,l become subject to the Worker's Compensation provisions of the the ifIII&Safety Cade,Se io 505,
Labor Code,I must forthwith comply with such provisions or this permit shall
be decreed revoked. Owner or authorized agent• -�
APPLICANT CERTIFICATION Date:06/14/2018
I certify that I have read this application and state that the above Information Is CONSTRUCTIO LENDING AGENCY
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 ARCH[TF.CT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Licensed
Signature Date 06/1412018 Professional