12060150 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 21866 HYANNISPORT DR CONTRACTOR: 11117 1IOME PERMIT NO: 12060150
IMPROV17MFNT SOURCE INC
OWNER'S NAME: ANDERSON GEORGIA L AND VERNON 1400 COLEMAN AVE STE 1115 DATE ISSUED:06/25/2012
OWNER'S PHONE: 4082536011 SANTA CLARA,CA 95050 PIIONE NO:(408)567-9710
❑ LICENSED CONTRACTOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT r PLUMB r
License Clercs Lic.p
MECH RESIDENTIAL COMMERCIAL
Contractor Dale
hereby affirm that l am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE SI IAICE ROOF,INS'T'ALL OSI).LII'ETIME
(commencing with Section 7000)of Division 3 of the Business&Professions ASPHALT
Code and that my license is in full force and effect. COMPOSITION SI IINGLES 30 SQFT
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
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 Cade,for the performance of the work for which this
permit is issued. Sq.FI Floor Area:0 Valuation:$14000
APPLICANT CERTIFICATION
1 certiry that I have read this application and stale that the above information is APN Number:35614061.00 Occupancy Type:
correct. I agree to comply with all city and county ordinances and stale laws relating
to building construction,and hereby authorize representatives of this city to enter
upon the above mentioned propertyfor inspection purposes. (We)agree to save
indemnify and keep hanlessthe City ofCupertino against Iiabililics,judgments, PERMIT EXPIRES IF WORK IS NOT STARTED
costs,and expenses which may accrue against said City in consequence of the
granting of this permit Additionally,the applicant understands and will comply WITHIN 180 DAYS OF PERMIT ISSUANCE OR
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSPECTION.
9.18.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
1 hereby affirm that l am exempt from the Contractor's License Law for one of RE-ROOFS:
the following two reasons: All roofs shall be inspected prior to my roofing material berg installed.If a roof is
I.as owner of the propeny,or my employees with wages as their sole compensation, installed without first obtaining an inspection.I agree to remove all new materials for
will do the work,and the structure is not intended or offered for sale(Sec7044, inspection.
Business&Professions Code)
I.as owner of the property.am exclusively contracting with licensed contractors to Signature of Applicant: Dale:
construct the project(Sec 7044,Business&Professions Code).
I hereby affirm under penally of perjury one of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BFITER
declarations:
I have and will maintain a Certificate of Consent to stir-insure for Worker's
11:\%:\RDOIIS NL\'I'F;RI:\LS DISCLOSURE
Compensation,as provided for by Station 3700 of the Labor Code,for the
performance of the work for which this permit is issued. I have read the hazardous materials requirements under Chapter 6.95 of the
I have and will maintain Worker's Compensation Insurance,as provided for by California Health&Safely Code,Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for the performance of the work for which this compliance with the Cupertino Municipal Code,Chapter 9.12 and the Health&
Safety Code,Section 25532(x)should I store or handle hazardous material.
permit is issued. Additionally,should 1 use equipment or devices which emit hazardous air
I cenif)'that in the performance of the work forwhich this permit is issued,I shall contaminants as defined by the Bay Area Air Qualfly\lanagemenl District I will
not employ any person in any manner so as to become subject to the Worker's maintain compliance with the Cupertino Municipal Code.Chapter 9.12 and the
Compensation laws of California. If,after making this certificate of exemption,I Health&Safety Code,Sections 25505,25533.and 25534.
become subject to the Worker's Compensation provisions of the Labor Code,I must
forthwith comply with such provisions or this permit shall be deemed revoked. Owner or authorized agent:
Date:
APPLICANT CERTIFICATION CONSTRUCTION LENDING AGENCY
I certify that I have read this application and stale that the above information is
correct. I agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is a construction lending agency for the performance of work's
to building construction,mid hereby authorize representatives of this city to enter for which this permit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes-(We)agree to save Lender's Name
indemnify and keep harmless the City of Cupertino against liabililies,judgments,
costs,and expenses which nmay accrue against said City in consequence of the Lender's Address
granting of this permit.Additionally,the applicant understands and will comply'
with all non-point source regula kens per the Cupertino Municipal Code,Section ARCHITECT'S DECLARATION'
9.18,
1 understand my plans shall be used as public records,
Signature Dale
Licensed Professional