12080052 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22597 ROYALOAK WAY CONTRAC'I'OR:PETERSEN-DEAN INC PF.RMITNO: 12080052
OWNER'S NASI Ii: BRAT IMANANDAM GORTI AND LALITA GORTI 7980 IrNTERPRISE DR DA'Z'E ISSUED:08/072012
OWNER'S PlIONEI: 4087256732 NE\\'ARK.CA 94560 PHONE NO:1510)494-9982
❑ LICENSED CON'I'RACFOR'S DECLARATION BUILDING PER tIIT INFO: BLDG [ ELECT I- PLUDIB (—
License Class Lie.#
plECll RESIDENTIAL COAIi\IERCIAL
Contractor Date
here by affirm Iha l l am licensed trader the provisions of Cha Ater 9 JOB DESCRI PTI ON: REMOVES[TAKE ROOF INSTALL PRESIDENTIALTL OVER
(commencing with Section 7000)of Division 3 of the Business&Professions 30#
Code and(hat me license is in full force and effect. FELT AND CDS PLYWOOD-9 SQ
hereby affirm under penalty of perjure one of the following two declarations:
I have and will maintain a certificate of consent to self-insure for Worker's
Compensation,as provided far 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
Section 3700 of the Labor Code,for the performance of the work for which this Sy.Ft Floor Area:0 Valuation:$5000
permit is.issued.
AI'('LIC\N'I'CI?If1'IFICA'1'I(hN APN Number:34232011.00 Occupancy Type:
I certify that I have read this application and state that the above infomuation is
correct.I agree to comply with all city and county ordinances mud stare laws relating
to building construction,mid hereby randomize 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 ol'Cuper ino against liabilities,judgments.
costs,and expenses which may accrue against said City in consequence of the WITHIN 180 DAYS OF PERMIT ISSUANCE OR
granting of this permit. Additionally,theapplicant 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 DECLARA'T'ION
RL:ROOFS:
1 hereby affirm that I am exempt from the Contractor's License Lame for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following Iwvo reasons: installed without 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 conirvi sation, inspection.
will do the work,and the structure is not intended or otfered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
L as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sce.7044,Business&Prokssions Code). ALI,ROOF COVERINGS TO BE CLASS"A"OR BOFTER
hereby affirm under penalty of perjury one of the following three
declarations: .AItDOl1S BL\"I'IiRIA LS DISCLOSUREI have and will maintain a Certificate of Consent to self-insure for Worker's
Compensation,as provided for by Section 3700 o'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 Ilrdth fi Safety Code.Sections 25505,25533.and 25534. I will maintain
I have and will maintain Worker's Compensation Insurance,a9 provided for by compliance wvi(h the Cupertino Municipal Code.Chapter 9.12 and the Health&
Section 3700 of the Labor Code,for the performance of lire%York for which this Safety Code.Section 25532(a)should I store or handle hazardous material.
Additionally,should I use equipment or devices which emit hazardous air
permit is issued. contaminants us defined by the Bay Area Air Quality Management District I will
I certify that in the performance of die 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 the Worker's Health&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,I must Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked. Dale'
APPLICA\T CERTIFICATION CONSTRUC`FION LIiNDING AGENCY
I certify that 1 have read this application and slate 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 law's relating for which this permit is issued(Sec.3097,Cir C.)
to building construction,and hereby authorize representatives ol'this city to enter Lender's Name
upon the above mentioned property I'or inspection purposes.(We)agree m 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 permit.Additionally,the applicant understands;aid will comply
with all non-point source regulations per tire Cupertino Municipal Code,Secti .UtCI l I'I'I':CI"S DECLARATION
9.18. 1 understand my plans shall be used as public records.
Signature Date Licensed Professional