B-2018-0587 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-0587
10629 RANDY LN CUPERTINO,CA 95014-2054(316 02 048) WESTSHORE
ROOFING INC
SAN JOSE,CA 95131
OWNER'S NAME: DATE ISSUED:04/10/2018
OWNER'S PHONE: PHONE No:(408)456-0200
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.#787221
Contractor WESTSHORE ROOFING INC Date 1113012018 X BLDG_ELECT_PLUMB
I hereby of@m that I am licensed under the provisions of Chapter 9(commencing —MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 ofthe Business&Professions Code and that my
license Is fn t'nll force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF PARTIAL;INSTALL IB(600 SF)
I hereby affirm under penalty of perjm•y one ofthe following two declarations:
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 ofthe work for which this permit is issued.
I have and will maintain Worker's Compensation Insurance,as provided for by
Section 3700 ofthe Labor Code,for the performance of the work for which this
permit is issued Sq.Ft Floor Area: Valuation:$5636.00
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 stale laws relating to building construction,and hereby authorize 316 02 048
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,casts,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 reilDER
s per the Cupertino Municipal Code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature -� Dale 04110/2018 Issued by:Jasmine Archbold
Date:04/10/2018
N' - E LARATI
Ihereby at'tir i that I am exempt from the Contractor's License Law for one ofthe RE-ROOFS,
following two reasons: All roofs shall be inspected prior to any roofing material being installed.Ira roar is
t. I,as owner ofthe property,or my employees with wages as their sole installed without first obtaining an inspection,I agree to remove all new materials for
compensation,will do the work,and the structure is not intended moffered for iuspec'm
sale(Sec.7044,Business&Professions Code)
z. I,os owner ofthe property,am exclusively contracting with licensed Signature of Applicant
contractors to construct the projact(See.7044,Business&Professions Cade). Date:04/10/2016
1 hereby affirm under penalty of parjm•y one of the following three declrrratie's' ALL ROOF COVEl2ING5 TO BE CLASS"A"OR BE'1"1'ER
r. I have and will maintain a Certificate of Consent to self-insure£or Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for due
performance ofthe work for which this permit is issued. HAZARDOUS MATERIALS DISCLOSURE
1. 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 ofthe Lobar Code,for the performance of the work far whicb this Calilarnia Health&Safety Code,Sections 25505,25533,and 25534.1 will
permit is issued. m n arms compffauce with the Coact him 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 255321 should I store or handle hazardous
shall not employ any person in any manner so as to become subject re the material.Additionally,should I use equipment or devices which emit hazardous
ah'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,Chapter 9.12 and
exemption,I beast forthwith
to c the Worker's Compensation provisions of the the Health&Safety Code Sections 75505,25573,n/t d 25534.
Labor Code,l must for0nwith comply with such provisions or this permit shall ✓�� "^"us.,'
be deemed revoked. Owner or authorized agent:
APPLICANT CERTIFICATION Date:04/10/2018
I certify that I have read this application and state that the above information Is CO STRUCTI N LE ) G AGEN Y
correct.I agree to comply with all city and county ordinances and state laws I hereby affirm that there Is a const ction f6riding 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,casts,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'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 04110/2018Licensed
Professional