03080167 CITY OF CUPERTINO
BUILDING DlvlsloN PERMIT ,CQNTR.CTOR�INFQRMATION ;-
9*.,.£,i42e°F `n.« .:.Yrpi; AaM;£3x:>ri•;Rj e- sc:*i2
BUILDING ADDRESS: PERMIT NO.
CHARU & AVINASH AGRAWAL 03080167
MrN!AMEI� PERMIT ISSUE DATE
ONE: SANITARY 0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
±00 LICENSED CONTRACTOR'S DECLARATION'
1 hereby affirm that I am licensed under Provisions of Chapter 9(commencing Job Description
withto n]IXg)or Division Sof cite Business,and Professions Code,and myiicmseis �'�����
in fullt]torte and c0en.
iq: LiccnseClue Lica REROOF
tor
I H Dete ContrT'S DECLARATION QQ ARCHITECT'S DECLARATION 6s 3
f 2 U 1 understand my plana shell M used n Public mcnNs SEP 16�2OOa7 '
e o Licensed Professional
OWNER-BUILDER DECLARATION WILDING
<y I hereby.('firm on 11. exempt from the Contractors License Lew for the �\
O o following reason.lownth III c1713,Business andimprove,
dprofession Code:AnY cin or county
5=OV which its requires a e,als re conswct,alter,imprnsm,demon"uh,or mash any awnum
ZN [hat heorm incensed pursuant
myuime prevision of forsucthe Contractor's
torile icense ned Law(Chapter
2:o (commesccgwithSectionNMIofvivionsnftftheBusinessandPrsclsw(Code)or Sq. Ft. Floor Area Valuaton
` $ (Cat he is(commencingwith Section and the
Division of the Business pt on.Any
of
Not he is exempt Nertfrom and the Esso for the alleged exemption.Any violation.f
Section 7031.5 by airy applicant fore permit subjects the aPPlmmt to a civil Penalty 9f APN Number _ _-. _ Occupancy Type
not more Nen five hundred dollus(5500). _ "" - - '-- -
❑1.As owner of the property,or my employees with wages u their sok compensation,
will do the work,and the sweture is not intended orofferid fornki(So.7W.Business 305 - FRAME
and Professions Code:The Contractor.License Law does not apply to an owner of Required Inspections
property,who builds or improves thereon,and who doeiuch work himselfor through his 307 - INSULATION
own employees,provided that such improwmenb ere not intended or offered for set&If. 601 — ROOF TEAR OFF
however,Nu e building or Improvement i.sold within one your of completion,the owner-
builder will ban Ne burden of proving that he did not build or improve fur purpose of 602 - ROOF PLYWOOD NAIL
mlc.).
01,as Owner of the propsny em exclusively contracting with licensed commicusra to 603 — ROOF BATTENS
construct the project(Sec.1060.Business and Prefentions Code:)The Contractor's Li. 604 - ROOF IN-PROGRESS
cense law does not apply to an owner of property,who builds or improv(Ammon,and,
who contracts for such projccu with a contractor)licensed pursuant o Ne Connector's
License Law.
]Iam/.'.ryy,(pq•/'��vOW�a16a,C�,�. B&PC for (moon
Owo Vl4}J ria y9!el f-W(JC �ne O _
RKE ' COMPENSATION DEC ATION -
1 thereby affi
rm under penalty of Perjury oro of the following doclentioc
n
I Mss and will mainuin a Cenificem or Consent m set(-insure for Worker's Compcn.
sation,es provided for by Section 7700 of the Labor Code,for the performance of the
work for which this permit is issued. _
❑1 have and will maintain Workers Compensation Insurance,u requited by Section
7700 of me Labor Code,for Ne performance of the work for which this Permit is issued.
My Workers Comreenthim fro mnce canner and Policy numbenrt:
Cartier. Policy No.:
CERTIFICATE OF EXEM MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not h.completed triple Permit is for one hundred dollen I$Hat)
nr to.$.) '
1 certify Nm in the performance of the work for which this Permit is issued.I shall not
employ any person in any manner an As in become subject m IN,Workr'Compematlon
Law s of California.Date
Applicant
NOTICE TO APPLICANT:IL after making this Cenilicate of Exemption,you Mould
become subject to the Worker's ComPensatimn provision.of the Labor end.,you most
Oforthwith comply with such provisions or this permit shall he deemed tcwlked.
Z�y CONSTRUCTION LENDING AGENCY
I hereby affirm that Vert its construction lending agency Tor the performance of
3i Ne work for which this Permit is issued($W.7097,Civ.C.)
31 Q Under,Name
z lenders Address /
J 1 cynify that I bete read this application and sum that lie above information is
y correct.1 agree to comply with all city and county oNinences and slate laws misting to
'U building convection,and hereby authuire mprerriadves of this city to enter upon me
W above-mentioned property for inspection purposes.
•y (We)agree to an.indemnify and keep harmless tM City of Cupertino against
h liabilities,judgments,Chun,and expenses which may in my way accrue against mid City
U Z in consequence of Ne granting of this permit.
APPLICANT UNDERSTANDS AND WILL MPLY WITH ALL NO -P01 Issued by: Date
ru'
Liec2 Re-roofs
HAZAR OUS MATERIALS DISCLOSURE sty Type of Roof
Ne applicant or future building occupant store or the Cupertino Municipal Code,Chapter 9.11,and the Health end Safety
n 13571(.)? All roofs shall be ins ected rlor to an roofin material bein Installed.
n t�Ne P P Y g gthe mpl Vin f/uw_rc buildingoccupem use eyuipmcnl or dcvicu whichIf a roof is installed without first obtaining an inspection,I agree to remove
us air conumimnu u defined by the Bay Arca Air Quality Management all new materials for Inspection.
E]Yes )<No
I haw foul me hmmdochur ZMalf requirements under Chapter 6.95 of tM Califon A
noes not hSafety hawRSentra, Sit i25AImd25576.IundernuWe ifVic huOfft U
acts not currently how•vmmr,Nu it u my responsibility m notify the axupmt of cite /
rerem. tpriortoits .raCertirteamofaapm.. ignature o App (cant - Date
Ow
ner.r a nn.e pies D . All roof coverings to be Class "B"or better
OWNER-BUILDER VERIFICATION
1. (Check one) I or gny immediate family (parent,spouse or child) will perform
A. All the work authorized by this permit
B. A portion of the work
C. None of the work
If B or C is checked,complete 2 or 3 below.
2. A state licensed contractor will be hired to do: RECEIVED
D
A. _ All of the work AUG 217 2003
B. A portion of the work (completes( ow)
Contractor Address/City Phone # rcense # Type of work to
be performed
3. _ I will utilize unlicensed person(s) other than my immediate family to perform all or
. portions of the authorized work. I understand that I may be an employer(see reverse side). A
Certificate of Insurance covering workers' compensation must be on file at the City of
Cupertino Building Department office.
Person/Firm Address/City Phone Number Type of work to be
erformed
.....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Information(reverse side). /
Property Owners Signature° Aate:
Job-Addiesm: 22 q Mc/C CL 1104, Pool, Permit# G
An changes to the information provided on this form shall be submitted to the QU of Cu ertino uild
Department.
I;ems
City of Cupertino Building Department
' I CITY OF 10300 Torre Avenu
C V P EST I N O Phone: (409) 777-3228
Dear Property Owner:
An application for a building permit has been submitted in your name listing yourself as the builder of
the property improvements specified.
For your protection you should be aware that as owner-builder you are the responsible party of record
on such a permit Building permits are not required to be signed by property owners unless they are
personally performing then own work. If your work is being performed by someone other than yourself,you
may protect vourself from possible liability if that person applies for the proper permit in his or her name.
Contractors are required by law to be licensed and bonded by the State of California and to have a
business license from the city or county. They are also required by law to put their license number on all
permits for which they apply.
If you plan to do your own work,with the exception of various trades that you plan to subcontract,you
should be aware of the following information for your benefit and protection:
If you employ or otherwise engage any persons other than your immediate family,and the work
(including materials and other costs) is$200 or more for the entire project,and such persons are not licensed as
contractors or subcontractors, then you may be an employer.
If you are an employer,you must register with the state and federal government as an employer and
you are subject to several obligations including state and federal income tax withholding,federal social
security taxes,workers' compensation insurance,disability insurance costs,and unemployment compensation•
contributions.
There may be financial risks for you if you do not carry out these obligations, and these risks are
especially serious with respect to workers compensation insurance.
For more specific information about your obligations under federal law,contact the Internal Revenue
Service (and,if you wish,the U.S.Small Business Administration). For more specific information about your
obligations under state law,contact the Department of Benefit Payments and the Division of Industrial
Accidents.
If the structure is intended for sale,property owners who are not licensed contractors are allowed to
perform their work personally or through their own employees,without a licensed-contactor or
subcontractor, only under limited conditions.
A frequent practice of unlicensed persons professing to be contractors is to secure an owner-builder
building permit,erroneously implying that the property owner is providing his or her own labor and material
personally. Building permits are not required to be signed by property owners unless they are performing
their own work personally:
Information about licensed contractors may be obtained by contacting the Contractors'State License
Board in your community or at 1020 N Street,Sacramento,California 95814.
Please complete and return the enclosed owner-builder verification form so that we can confirm that
you are aware of these matters. The building permit will not be issued until the verification is returned.
Very truly yours,
Building Department,
City of Cupertino
Printed on Recycled Paper
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
My+0e
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
OUPEkTINO
Building Department
Subject: Re-roofing policy for the City of Cupertino
1. Prior to permit issuance,you must agree to comply with 1997 UBC Standards
and manufacturers specifications on re-roofing.
2. New roof coverings shall not be applied without first obtaining all inspection
and written approval from the building inspector. A final inspection and
approval shall be obtained from the building inspector when the re-roofing
is completed.
3. All roofs shall be inspected prior to any roofing installation.
4. To receive a final sign off from the City, the following ste C Vr'.
required: AU 03
1) Pre-inspection and/or tear off approval.
2) In-progress inspection approval. BY:
• 3) Final inspection approval.
a) Spark arrester installation.
5. If plywood is installed,a plywood nail inspection is required.
6. Any roofing which is applied without first obtaining an inspection,
Will require the removal of all new material down to the sheathing,
so a proper City inspection can be performed.
IMPORTANT:
1. Flat roofs must have a minimum of 1/4 " per foot slope and demonstrate
that there is no ponding.
2. An I.C.B.O. report is required to be on the job site at the time on inspection.
I understand and will comply with the above stated policy on re-roofing.
Homeowner's Name: ONMV K_ �/li1/}� yH AftietgW h
Job Site Address: Z-7io ( E LLI V k-0-14-3)
Roofing Company Name: r--- —
Aplicant's Signature: Date: 7 �
I I�
\�1/4S1�l1DLX)
Greg teel
Building Official
Revised 1/30/03
Printed on Recycled Paper
OF
CITY RERTINOR OF3 �,
o cl6
CUPEkTINO PERMIT APPLICATION FORM
APN# 33 I yt��/ Date:
Building Address: (� V
2-2,0E.JACtellonleo CA S`a l y- u66Z
Owner's Name: f Phone #:
C4-t►�i2 b� � sH A-C�i�Flw Fl 1, y� - 7 u
Contractor: Phone#: License#:
OW
Contact: Phone#: Cupertino Business License#:
Type of Roof Covering:
Existing: Proposed:
❑ Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles Asphalt Shingles
¢� Wood Shakes ❑ Wood Shakes
(] Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ❑ Other(Specify)
Number of existing coverings ❑ Provide I.C.B.O.Report#
❑ To be Removed ❑ Provide Mfgr. Installation Specs.
. I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy:
Job Description:
R�mo�� e-l� sake �' a.ry insl�-U d -t sl.,
Residential �( Commercial ❑
Fire Zone: /Yes ❑ Confirmed with ning D� .
there are an estrictions: LJ
Cost Project: Type of Const n: Occup group:
�^ 6000
Qty. t
A lic b e Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING
O
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