12090184 CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22388 SANTA PAULA AVE C0YI'RAC`F0R:NEW WORLD BUILDER PERMIT NO: 12090184
ONSNER'S NAME:.GUPTA RAJAT AND PUJA 1196 BRANDYBOOD WAY DATE ISSUED:09/2012012
OWNER'S PHONE.: 9259171046 SAN.IOSIS,CA 95121 PHONE NO:(408)472-3692
❑ LICENSED CON'1'RAcrOR'S DECLARATION BUILDING PERMIT INFO: BLDG r ELECT rl PLUMB
License Class Lie.q
i111EC11 r RESIDENTIAL❑ COMMERCIAL r
Contractor Date
I hereby affirm that I not licensed under the provisions of Chapter 9 JOB DESCRIPTION:ADDITION AND REMODEL OF EXISTING HOUSE.NEED
(commencing with Section 7000)of Division 3 of the Business&Professions TEbIPORARY POWER DURING CONSTRUCTION.
Code and that my license is in full force and effect.
hereby affirm under penalty of perjury one of the folioMing 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
performance of the work for which this penton 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 Sq.Ft Floor Area:0 Valuation:$300000
permit is issued.
APPLICA\1'CFRTIFICATION APNNumber:35705034.00 Occupancy Type:
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 and suite 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 harmless the City of Cupertino against liabilities,judgments,
costs,and expenses which may accmc against said City in consequence ofthe WITHIN 180 DAYS OF PERMIT ISSUANCE OR
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.
Signature Date Issued by: Date:
❑ OWNER-BUILDER DECLARATION
RF--ROOF'S:
I hereby affirm that I am exempt from the Contractor's License Law for one of All roofs shall be inspected prior to any roofing material being installed.If a roof is
the following["a 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 compensation, inspection.
will do the work,and the structure,is not intended or offered for sale(Sce.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as ownerof the property,am exclusively contracting with licensed contractors to
construct the project(Sec.7044,Business&Professions Code). ALL ROOF COVERINGS'1'O Ill,CLASS"A"OR BETTER
hereby affirm under penalty of perjury one of the following three
declarations: HAZARDOUS MATERIALS DISCLOSURE
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 I 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 by compliance with the Cupertino pl unicipal Code,Chapter 9.12 and the Health&
Section 3700 of the 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 die work for which this permit is issued,I shall maintain compliance e'ith 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 Mulch&Safety Code,Sections 25505,25533,and 25534.
Compensation laws of Cali forma. If,after making this cenillealC of exenmption,1
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 perit shall be deemed revoked Date:
CONSTRucrioN LENDING AGENCY
API'LIC,kN'I'CFR'rIFICATION
I certify that I have read this application and 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 laws relating for which this permit is issued(Sec.3097,Civ 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 accmc against said City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCI IITF-cl"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