12090143CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 10421 LANSDALE AVE
C0N'TRAC`fOR: PETERSEN-DEAN INC
PERMiTNO: 12090143
OWNER'S NAME: COONS JOHN K AND DIANE M
7980 EN 1'F,RPRISE DR
DATE ISSUED: 09/17/2012
OWNER'S PHONF: 4084461747
NEWARK. CA 94560
PHONE -NO: (510)494-9982
❑ LICENSED CO\ TRACTOR'S DECLARATION'
(✓ ❑
BUILDING PERNUT INFO: BLDG ELECT PLUMB
License Class Lie.q
r_ r F�
DIECH RESIDENTIAL COMMERCIAL
Contractor Date -
I hereby affirm that I am licensed under the provisions of Chu pier 9
JOB DESCRIPTION: REMOVE EXISTING WOOD SHAKE INSTALL NEW
(commencing with Section 7000) of Division 3 of the Business & Professions
T ILE-37 S IGHT
IG37 SQ
Code and that my license is in full force and effect
hereby affirm under penalty of perjury one of the following Ian 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
Sq. Ft Floor Area: 0
Valuation: $17782
Section 3700 of the Labor Code, for the performance of the work for which this
pemnit is issued.
APN Number: 36911006.00 Occupancy Ty pe:
APPLICANTCERTIFICATION
I certify that I have read this application and stale that the above infamtation is
correct. I agree to comply with all city and county ordinances and state 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
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep Immiless the City of Cupertino against liabilitics,judgmemS,
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs, and expenses which may accrue against said City in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Issued by: Date:
Signature Date
❑ OWNER -BUILDER DECLARATION
RE -ROOFS:
hereby affirm that I am exempt from the Contractor's License Lays for one of
All roofs shall be inspected prior to any roofing material being installed If a roof is
the following two reasons:
installed without first obtaining an inspection, I agree to remove all new materials for
1, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or offered for sale (Sec.7044,
Business & Professions Code)
Signature of Applicant: Date:
I, as Owner of the property, am exclusively Contracting with licensed contractors l0
construct the project (Sec.7044, Business & Professions Code).
ALI, ROOF COVERINGS TO BE CUSS "A" OR RE ITER
hereby affirm under penalty of perjury one of the fullowing three
declarations:
IL�7.ARDOLIS d1A"fF:RIALS DISCLOSURE
1 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
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this permit is issued.
California Ilealth & Safety Code. Sections 25505, 25533, and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance, as provided for by
compliance with the Cupertino Municipal Code. Chapter 9.12 and the Ilealth &
Safety Code, Section 25532(a) should 1 store or handle hazardous material.
Section 3700 of the Labor Code, for the performance of the work for which this
Additionally. should I use equipment or devices which emit hazardous air
permit is issued.
contaminants as defined by the Day Area Air Quality Management District 1 will
I certify that in the performance of the work for which this pemnit is issued, 1 shall
maintain compliance with the Cupertino Municipal Code, Chapter 9.12 and the
not employ any person in any manner so as to become subject to the Worker's
Ilealth & Safety Code, Sections 25505. 25533, and 25534.
Compensation Ines of Cali fomia. IC aer making this certificate of"exennplion; I
become subject to the Worker's Compensation provisions of the Labor Code, I must
Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked.
Date:
CONSTRUCTION LENDING AGENCY
APPLICANT CFRIIhICA'TION
I certify that I have read this application and stale that the above information is
I hereby affirm that there is a construction lending agency for the performance of vmrk's
correct. I agree to comply with all city and county ordinances and state Imes relating
for which this permit is issued (Sec. 3097, Cie C.)
to building construction, and hereby authorize representatives of this city to enter
Lender's Name
upon the above mentioned property for inspection purposes. (We) agree to save
indemnify and keep harmless the City of Cupertino against liabilities, judgments,
Lender's Address
costs, and expenses which may acerae against said City in consequence of the
'
graining of this permit. Additionally, the applicant understands and will comply
ARCAITFC`I"S DECLARATION
with all non -point source regulations per the Cupertino Municipal Code, Section
9,18,
1 understand my plans shall be used as public records.
Signature Dale
Licensed Professional