12100099 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRI?SS: 11635 OAK SPRING CT CON'T'RACI'OR:'I'D ROOFING PERMIT NO: 12100099
O\VNER'S NAME: TZENG KARL T AND FLORA W 675 TULL1'RD DATE ISSUED: 10/122012
OWNER'S PlIONE: 4087181503 SAN.IOSF,.CA 95111 PHONE NO:(408)892-8872
❑ LICENSED CONIRACI'OR'S DECLARATION BUILDING PERMIT INFO: BLDG I_ ELECT❑ PLUMB IJ
License Class Lie.q
NIF.CII r RESIDENTIAL 'I COMMERCIAL Ci
Contractor Date
1 hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION:REMOVE WOOD INSTALL GAF OVER EXISTING OSB 15q
(commencing with Section 7000)of Division 3 of the Business&Professions FELT 19 SQ
Code and that my license is in full force anil effect.
hereby affirm under penalty of perjury one of the following two declarations:
I have and will maintain a certificate of consent to self-insure I'or Worker's
Compensation,as provided for by Section 3700 of die 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 Code,for the performance of die work for which this Sq.Ft Floor Area:0 Valuation:$9300
permit is issued.
APPLIGSN'1'CISR'1'I1-'ICA'I'ION APN Number:36652074.00 OccupancyType:
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 mid state laws relining _
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 harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
graining 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
Rh;ROOFS:
hereby affirm that I am exempt from the Comructor's License Law 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 now materials for
1,as owner ollhe property,.or my employees with wages as their sole comp_nsation, inspection.
will do the work,and the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
1,as owner of the property,ant exclusively contracting with licensed commetors to
construct the project(Sec.7044,Business& Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR 11EITER
hereby affirm under penalty of perjury one of the fallowing three
declarations:
I have and will maintain a Certificate of Consent to self-insure for Worker's HAZARDOUS MATERIALS DISCLOSURE
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. I 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 Health&
Section 3700 of the Labor Code,for the performance ofthe work for which this Safety Code.Section 25532(a)should Ismre or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued, contaminants as defined by the Bay Area Air Quality Jlanagement District 1 will
I certify that in the performance of die work for which this permit is issued,l 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 laws of California. If,after making this certificate of exemption,I
become subject to the Worker's Compensation provisions of the Labor Code,1 must Ou'ner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked Date.
APPLICANTCERTIFICATION CONSTRUCTION LENDING AGENCY
I cenifv that I have read(his application mid state that the above information is I hereby affirm that there is a construction lending agency for the performance of work's
correct.I agree to comply with all city and county ordinances and state Imus relating for which this pemhit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city t0 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
granting of this permil.Additionally,the applicant understands and will comply ARCI IITTECI"S DECLARATION
with all non-point source regulations per the Cupertino Municipal Code,Section
9.18. I understand my plans shall be used as public records.
Signature Date Licensed Professional