12100196 (2) CITY OF CUPERTINO BUILDING PERMIT
BUILDING ADDRESS: 22466 LINDA ANN CT CONTRACT OR:LOS GATOS ROOFING PERMIT NO: 12100196
OWNER'S NAME: JAWAHAR MALHOTRA I'D BOX 1726 DATE ISSUED: 10262012
OWNER'S PBONF,: 4089405019 LOS GATOS.CA 95031 PI IONE,NO:(408)298-9399
❑ LICENSED CONTRACFOR'S DECLARA'T'ION BUILDING PERMIT INFO: BLDG r ELECT I. PLUMB Cl
License Class Lie.# r T-1 ['
\tECH RESIDENTIAL COMMERCIAL
Contractor Date
hereby affirm that 1 am licensed under the provisions of Chapter 9 JOB DESCRIPTION: REMOVE EXISTING WOOD SHINGLE/SI'IAKE ROOFING.
(commencing with Section 7000)of Division 3 of the Business& Profeesions INSTALL 40 SQ OSB N ITII RADIANT 13ARRIER AMD
Code and that my licenseis in full force and effect. WOODMOOR LIFETIME COMP BY OWENS CORNING.
I herchy affirm under.penalty M perjury one of the following oro 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,far the
performance of 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.F( Floor Area:0 Valmition:$14437
permit is issued.
APPLICANq'CF.R'1'I1:IC,%TI0N APNNumber:32613071.00 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,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
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.
Issued by: Date:
Signature Date
❑ OWNER-BUILDER DECLARATION
RF,-ROOFS:
I hereby affirm that I out exempt from the Contractor's License Lass for one of All roofs shall be inspected prior to any roofing material beiig installed Ira roof is
the following reo reasons: installed withma 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 simeture is not intended or offered for sale(Sec.7044,
Business&Professions Code) Signature of Applicant: Date:
I,as owner of the property,am exclusively contracting with licensed contractors to
construct the project(Sec7044,Business&Professions Code). ,\LI.ROOF CO\'FRINGS'1'O BECLASS".\"OR'BE'17ER
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 HAZARDOUS MA'T'ERIALS 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 Health&Safety Code.Sections 2550.5,25533,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 Health&
Section 3700 of the Labor Code,for the performance of the work 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 as defined be the this.Arca 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 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 Owner or authorized agent:
forthwith comply with such provisions or this permit shall be deemed revoked: Date:
APPLICANTCERTIFICA'T'ION CONSTRUCHON LEINDING AGENCY
I certify that I have read this application and state that the above information is I hereby affirm that there is aconstruction lending agency for the performance of ourk's
correct.I agree to comply with all city and county ordinances mid 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 Leader'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 City in consequence of the
granting of this permit.Additionally,the applicant understands and will comply ARCAI'11SC1'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