12070161CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 20381 CLIFDEN WAY
CONTRACTOR: HOMEOWNER
PERMITNO: 12070161
OWNER'S NAME: ATUL & MEEI'A PATEL
IN
DA'Z'E ISSUED: 07/19Q012
OWNER'S PHONE: 4084251193
CUPERTINO, CA 95014
PHONE NO:
❑ LICI.NSF,D CON I'RACI'OR'S DECLARATION
1- 1-1 F.
13UILDING PERMIT INFO: 13LDG ELECT PLUMB
License Class Lie.H
r r -'
DIECH RESIDENTIAL COpIDIERCIAL
Contractor Date
1 hereby affirm that I and licensed under the provisions of Chapter 9
JOB DESCRIPTION: RESIDENTIAL RE -ROOF. TEAR OFF ALL WOOD SHINGLES
(commencing with Section 7000) of Division 3 of the Business & Professions
AND REPLACE WITH 20YR COMPOSITE ROOF-33SQFT
Code and that my license is in full force and effect.
hereby affirm under penalty of perjuryone 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
perlornance of the work for which this permit is issued.
I have and will maintain Workers Compensation Insulralce, as provided for by'
Sq. Ft Floor Area: 0
Valuation: $20000
Section 3700 of the Labor Code, for the performance of Ole work fonvhich this
permit is issued.
AI'N Number: 36937012.00 Occupancy Type:
AI'PI,ICA\I'CER'1'I1;ICA9'10N
I certify that I have read this application mid state that the above infomlation is
correct. I agree to comply with all city and county ordinances and slate Imus relating
to building construction, and hereby authorize representatives of this city to enter
upon the above mentioned property for inspection purposes. (We) agree to save
PERMIT EXPIRES IF WORK IS NOT STARTED
indemnify and keep City of Cupertino against
hichr n%, a onseiuenceithe
costs, and expenses which may acerae against said City in consequence o(lhe
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting ofthis permit. Additionally, the applicant understands and will comply
180 DAYS FROM LAST CALLED INSPECTION.
with all non -point source regulations per the Cupertino Municipal Code, Section
9.18.
Issued by: Dale:
Signature Date
❑ O\\'NFK-IfIIILUIiK UICCLARA'I'ION
RE ROOFS:
I hereby affirm that 1 am exempt from the Contractor's License Law for one of
All roofs shall be inspected prior to any roofing material beiig installed If a roof is
the following two reasons:
installed w'ithora first obtaining an inspection, I agree to remove all new materials for
I, as owner of the property, or my employees with wages as their sole compensation,
inspection.
will do the work, and the structure is not intended or of Bred for sale (Sec.7044,
Business & Professions Code)
Signature of Appli=t: Date:
I, as owner of the property, am exclusively contracting with licensed contractors to
construct line project (Sce.7044, Business & PmIC55ions Code).
,\I,I, ROOF CO\'I$RL\G$1 O BE Claw$$ ".\" DK ISIi'1-I'ISR
hereby affirm under penalty of perjury one of the following three
declarations:
I have and will maintain a Certificate of Consent to self -insure for Worker's
IIA'l.AKDOIIS \L\TERLUS DISCLOSURE
Compensation, as provided for by Section 3700 of Ole Labor Code, for the
I have read the hazardous materials requirements under Chapter 6.95 of the
performance of the work for which this perhit 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 by
compliance with the Cupertino Municipal Code, Chapter 9.12 and the Ilealth &
Section 3700 ofthe Labor Code, for the performance of the work for which this
Safety Code. Section 25532(x) should I 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 Management District I will
I certify that in the performance of the work for which this permit is issued, I 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 die Worker's
Ilealth & Safety Code, Sections 25505, 25533, and 25534.
Compensation laws of California. If, ruler making this certificate orexemption, I
become subject to the Workers Compensmion provisions oftie Labor Code. 1 most
Owner or authorized agent:
forthwith comply with such provisions or [his permit Shall be deemed revoked
Date:
CONSTRUCTION LENDING AGENCY
APPLICANT CERTIFICATION
I certify that I have read this 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 mid stale laws relating
for which this permit is issued (Sec. 3097, Civ C.)
to building construction, mid 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 accrue against said Cit' in consequence of the
granting of this permit. Additionally, the applicant understands and will comply
ARCD ITECI" 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 Date
Licensed Professional