12080053 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22587 ROYAL OAK WAY CONTRACFOR:PETERSEN-DEAN INC PERMITNO: 12080053
OWNER'S NAME.: DEEPAK&1YOTI RHARGAVA 7980 ENTERPRISE;DR DATE ISSUED:08/072012
OWNER'S PRONE: 4087256732 NFNVARK.CA 94560 PHONE NO:(510)494-9982
❑ LICENSED CONTRACT'OR'S DECLARATION BUILDING PERMIT INFO: RLDC r ELECT r' PLUMB r
License Class Lie.4
NlECii (- RESIDENTIAL r COMMERCIAL r
Contractor Dale
I hereby affirm that I am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE SHAKE ROOF INSTALL PRESIDENTIAL TL OVER
(coil)locating with Section 7000)of Division 3 of the Business&Professions 304
Code and that niv license is in full form and effect. FFIA AND COX PLYWOOD-9 SQ
I hereby affirm under penalty of perjury one of the following Eva 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,asprovided for by
Section 3700 of the Labor Code,.for the performance of die work forwhich this Sy.Ft Floor Area:0 Palmation:$5000
pemnit is issued.
AI'1'I.ICAN'I'CER'I'IFICA'I'ION AI'N Number:34232012.00 Occupancy'Type:
I certify that I have read this application mid state that the above information is
correct.I agree to comply with all city and county ordinances and state laws relating
to building construction,mid hereby authorize representatives of(his city to enter
upon theabove mentioned property for inspection purposes. (We)agree to save PERMIT EXPIRES IF WORK ISNOT STARTED
costs,ande pensee hick sstheya City'of Cupertino againstliabilities.judgments, WITHIN 180 DAYS OF PERMIT ISSUANCE OR
costs,and expenses which may accrue against said City in consequence of the
grunting of this permit. Additionally,the applicant understands and will compl) >,
with all non-point source regulations per the Cupertino Municipal Code,Section 180 DAYS FROM LAST CALLED INSI ECTION.
9.18.
Issued bv: Date:
Signature Date
❑
OWNER-BUILDER DECLARATION
RP:ROOFS:
I hereby affirm that 1 not exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material beiig 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,mid the structure is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as ovnerof the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS TO BE CLASS"A"OR BE"I'fER
I hereby affirm under penally of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self insure for Worker's I IA""LARDOUS MATERIALS DISCLOSURE
Compensation,as provided for by Section 3700 of the Labor Code,for the 1 have read the hazardous materials requirements under Chapter 6.95 of the
performance of.the work for which this permit is issued California health&Safety Code,Sections 25505.25533.and 25534. 1 will maintain
I have and will maintain Worker's Compensation Insurance,as provided for be compliance with the Cupertino Nlunicipal Code,Chapter 9.12 and the health&
Sec(ion 3700 of the Labor Code,for the performance of the work for which this Safety Code Section 25532(a)should].store 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 NI a nagem eat District I will
I cenify that in the performance of the work for which this permit is issued,I shall maintain compliance with the Cupertino Nlunicipal Coda Chapter 9.12 and the
not employ any person in my manner sons to become subject to the Worker's I Ieafth&Safely Coda Sections 25505,25533,and 25534.
Compensation laws of California. If,after making this certificate of exemption,I
become subject to[lie Worker's Compensation provisions ofthe Labor Code,I must Owner or authorized agent:
lorth with comply with such provisions or this permit shall be deemed revoked Date'
CONSTRUCFION LENDING AGENCY
APPI.ICAN'r CliR'Tn'IC,%'I'ION
I certify that I have read this application and state that the above information is I hereby affirm that thereis a cohsuuction lending agency for the perforrna ce of+wrk's
correct.'I agree to comply with all city and county ordinances and state laws relating for which this pemtit is issued(Sec.3097,Civ C.)
to building construction,and hereby authorize representatives of this city to enter Leader's Name
upon the above mentioned property for inspection purposes.(We)agree to save
indemnify and keep harmless the City of Cupertino against Iizbilitics,judgments, Lender's Address
costs,and expenses which may accrue against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply AI2CI II"I'ECI"SDFCLAIi.\TION
with all non-paint source regulmiais per the Cupertino Municipal Code,Section
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional