12080049 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRFSS: 22627 ROYAL OAK WAY CO\IRACI'OR:PET[RSGN-DEAN INC PERMIT NO: 12080049
OWNER'S NAAIF: LE IIUE N 7980 F.\I'ERPRISF DR DATE ISSUED:08107/2012
OWNER'S Pl IONE: 4087256732 NF\VARK.CA 94560 PIIONENO:(510}194-9982
❑ LICENSED COVIRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT(- PLLINIR r
License Class Lie.#
DIECII r RESIDENTIAL r COMMERCIAL r
Contractor Date
hereby affirm that l am licensed under the provisions of Chapter 9 3013 DESCRIPTION:REMOVE SHARE ROOF INSTALL PRESIDENTIAL TL OVER
(commencing ith Section 7000)of Division 3 of the Business S Professions 30#
w
Code and that m ,license is in full force and effect. FELT AND CDS PLYWOOD 9 SQ
hereby affirm under penalty of perjury(tile of the following tyro decla
rations:I have and will maintain a cent ficate of consent 10 sel6insure for Worker's
Compensation,as provided for by Section 3700 of the Labor Code,for the
performance of 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 perfonnmice of die work for which this
Permit is issued. Sq. Ft Floor Area:0 Valuation:$5000
,\I'I'I.ICAN'I'CER'I'IFIG\'I'If1,N
I certify that I have read this application and State that the above information is ,U;N Number.34232008.00 Occupancy-Type:
coffeeL I acne to comply with all city and county ordinances and slate laws relating
to building construction,and hereby authorize 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. 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-BIIILDFR DECLARATION
hereby affirm that I am exempt from the Contractor's License L any for one of RE ROOFS:
the following boo reasons: All roofs shall be inspected prior to any roofing material beiig installed.If o roof is
I,as owner of the property,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(Sce.7044, inspection.
Business R Professions Cade)
I,as owner of the property,am exclusively contracting with licensed contractors to Signature of Applicant: Date:
construct the project(Sec.7044,Business Q Professions Code).
hereby affirm under penalty(if perjury Oise of the following three ALL ROOF COVERINGS TO BE CLASS"A"OR BF'17ER
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIAE S DISCLOSURE.
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 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 Ileulth S Safeq.Code,Sections 25505,25533,and 25534. 1 will maintain
Section 3700 of the Labor Code,for die performance of the work for which this Compliance with the Cupertino Municipal Code,Chapter 9.12 and the Ilcalth S
Safely'Code.Section_553_(8)should I store or handle hazardous material.
permit is issued Additionally,should I use equipment Or devices which emit hazardous air
I certify that in the performance of date work for which this permit is issued,I shall contaminants its defined by the Ray Area Air Quality Management Dk rict I will
mm 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,aRer making This cenificate ofexenmptioo,I Ilcalth S Safely Code,Sections 25505,25533,and 25534.
become subject to the Worker's Conmpensmion provisions of the Labor Code.I must
forthwith comply with such provisions or this permit shall he deemed revoked. 0a ner or authorized agent
DBic:
\I'I'LIC.\N'I'CISR'I'IFICA'TIf6N CONSTRUCTION LENDING AGENCY
I certify that I have read this application and state that the above information is
correct.1 agree to comply with all city and county ordinances and state laws relating I hereby affirm that there is u construction lending agency for the performance of swrk's
to building construction,mid hereby authorize representatives ollhis city to enter for which this pennit is issued(Sec.3097,Civ C.)
upon the above mentioned property for inspection purposes.(We)agree to save Lender's Name
indemnityand keep harmless the City ol'Cupenino against liabilitics,judgments,
costs,and expenses which may acerae 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 regulations per the Cupertino Municipal Code,Sections ,\RCII I"I'FCI"5 DECLARATION9.18.
I understand my plans shall be used as public records.
Signature Date
Licensed Professional