B-2018-1188 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: CONTRACTOR: PERMIT NO:B-2018-1188
6104 WILLO WGROVE LN CUPERTINO,CA 95014-4649(375 38 017) COSMOS ROOFING
INC
MOUNTAIN VIEW,CA
94043
OWNER'S NAME:HUNSINGER DAVID LAND YANT HUNSINGER MELISS DATE ISSUED:07/12/2018
OWNER'S PHONE: PHONE NO:(650)969-7663
LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO:
License Class C39 Lic.4785441
Contractor COSMOS ROOFING INC Date 04130/2019 X BLDG_ELECT_PLUMB
I hereby affirm that I am licensed under the provisions of Cha ter 9(commencing _MECH X RESIDENTIAL_COMMERCIAL
with Section 7000)of Division 3 of the Business&Professions Code and that my
license is in full force and effect. JOB DESCRIPTION:
RE-ROOF;TEAR-OFF;INSTALL TAR AND GRAVEL ROOF(4 PLY
I hereby affirm under penalty of perjury one of the following five declarations: COOL CAP)-(24 SQ)
1. I have and will maintains 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 of the Labor Code,for the performance of the work for which this
permit is issued. Sq.Ft Floor Area: Valued—$11995.00
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 375 38 017
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 Cit inconsequence of the granting of this permit. WITHIN 180 DAYS OF PERMIT ISSUANCE OR
Additionally,the eppl til unde lands and will comply with all non-point
source regular e p Ino Municipal code,Section 9.18. 180 DAYS FROM LAST CALLED INSPECTION.
Signature Date 07112/18 Issued by:Haley McKec
Date:07/12/2018
OWNER-BUILDER DECLARATION
I hereby affirm Rod I am exempt from the Contractor's License Law for one of the RE-ROOFS:
following two reasons: All roofs shall be inspected no rooting 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 obtai ng au inspe t I agree to remove all new materials for
compensation,will do the work,and the structure is not intended or offered for ' on.
sale(Sce.7044,Business&Professions Code) -
z. 1,as owner of fhe property,am exclusively contracting with licensed Signutme ofApph.
contractors to construct the project(Sce.7044,Business&Professions Code). Date:07/12/18
I hereby affirm tinder penalty of perjury one of the following three declarations: ALL ROOF COVERINGS TO BE CLASS"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 the 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 end the
s. I certify that in the performance of the work for which this permit is issued,I Health&Safety Code,Section 255321 should 1 store or handle hazardous
shall not employ any person in any manner soar to become subject to the innterial.Additionally,should I use equipment or devices which emit hazardous
us
as delated by the Ba ca Ai ura ity Management District I
Worker's Compensation laws of California.If,after making this certificate of will maintain compliance with the pertino Muni' 1 Code,Ch spier 9.12 and
exemption,I become subject to the Worker's Compensation provisions of the the Health&Safe ..Co Se tions 2 505, 533,and 25534.
Labor Code,I must forthwith comply with such provisions or this permit shall
be deemed revoked. Owner or authorized age
APPLICANT CERTIFICATION Date:07/12118
I certify that I have read this application and state that the above information is CONSTRUCTION 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 ARCIATECT'S DECLARATION
Code,Section 9.18. 1 understand my plans shall be used as public records.
Signature Date 07!12!18 Professional
Licensed