03030050 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFQRMATION
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BUILDING ADDRESS: SHEKAR PASUMARTHI PERMIT NO.
OWNER'S NAME: APPLICATIO
JNE: SANITARY N0. CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION ]obDescri tion
Wt 1 hereby afOrm Nal 1 em IittaW under provuira of Chapter Y gnmmencing p
n2 with Section 7"r.f Division Sof the Bues
sinsend Pmfcssiona Code.ard my license is
<< o full fonts end effect,
5naLicense Class Lk.N REROOF
3H naw Contractor T/O WOOD SHAKES & REPLA G W 1/2"OSB &
ARCHITECTS DECLARATIONk!U L ��®
lundcrsund my plans shallWused as public records ASPHALT SHINGLES -IN
O Licensed Pndessional
m
OWNER-BUILDER DECLARATION MAR 1 9 200
I hereby affirm Chet 1 am exempt from the Commodes License Lew for the
00 following mason.(Section 7031.5.Business and Professions Code:Any city or county ,
g� which requims a permit to construct,atter,improve.demolish,or repair any strocture
FZt" prior to its issuance,also requires the applicant for such permit mile a signed statement
H't thatheislicensedpmwanttothePmvisimooftheContractor'sLimnseLA.lChepter9 Sq.Ft. Floor Area WILDINJOluation
(commencing with Section 7o00)or Division 3 of the Businessand Professions Code)or
o
that he Is exempt tbemfrom and One basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Osggp@71py Type
not mom then five hundred dolhrs(5500).
❑I,as owner of the property,or my employees with wages as their sole compensation.
will do the work.and Raiment.I,not intended or offered foraale(Sec.70,14,Business 36932047 . 00 Required Inspections
and Pmfeulans Code:The Contractor's License law aloes not apply to an owner of q p
property,who Wildsor improves thereon.and who doessuch work himself orthrough hit
Own employ=.provided that such improvements are not intended mothered for sale.If. 305 — FRAME
however,be building or improvement is sold within one year of completion,the owner.
builder will have the burden of proving that he did not Wild or improve for purpose of 307 - INSULATION
tale 1.
❑1,as owner of the property,em exclusively contracting with licensed conmcmrs On 601 - ROOF TEAR OFF
construct the project(Sec.7014,Business and Profusions Code:)The ConuseresLl• 602 — ROOF PLYWOOD NAIL
moss law does not apply to an owner of propcny who Wilda or improves thereon,and 603 ROOF. BATTENS
he contracts for such projects with a conhot fire licensed pursuant e Concto
ate" "w' 604 - ROOF IN-PROGRESS
Q am exempt under Sec. ,B k P C for this recon
wn r 5Nf311Gan �GASUyA�fhty me 3 a
WORKLR'SC MPENSATION DELL sTRA '
I hereby affirm under penalty of perjury ore of the ollowingdeclarnioa: '
I he and will maintain s Cerfriceteof Content to rel6insom for WorkeM1 Compere
setirn,u provided for by Scctirn 3700 of Ne labor Cnde.for Ne perfrrmancc of the -
work for which this permit is issued.
❑1 hast and will maintain Worker's Compensation Insurance,as required by Section
3700 of the lobar Cod0.for the performance of the work for which this permit is issued.
My Workers Comic nsailon Insurance carrier and Policy numher are:• '
Cartier: Polity No.:
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
. (fhessfellonneed nm hecumplmed ifthe permit is fortune hundred dollars($100)
or less.)
1 artily thnI in the perfn ancc of the wmk far whihckh�Nis permh is issued,l shell not
employ any itrwrLL anner so�iih c ry s O mthc Wmkcrs'Cnmpe satlon
Laws of Celifornipp..Dem
Applaal SI.f alt S 7 s
NOTE 1 APPLICANT.If,after making this Cediricak 6rEfsemption,you should
become subject to the Workers Compensation provisions of the Labor Code,you must
., O forthwith comply with such provisions orthispornit shall W deemed revoked.
y CONSTRUCTION LENDING AGENCY
f" Ihereby art.that there iso cmurtcumt lending egenry for Ne parformeac of
(� r7 the work for which this permit is issued(Sec.3097,Civ.C.)
QLender's Name
z Lendcr'sAddress
V 0 I certify that 1 have read this application end sure that the show infomntiun is -
[6 correct.I agree to comply with all city and county ordinances and show laws relating to
0 building construction,and hereby suthnrire mpresentatives of this city to enter upon the
t31 41 ovomentioned pmperty(or inspection purposes.
UC (We)seg.m...indemnify and keep humless the City of Cupertino against
fn incoise consequence
of the cosuend ofpemeswhich may in any wyemuc against said City
fJ r7•� inconseyucnec oflAc grantingANDS AND
APP CANT UNDERSTANDS AND WILL COMPLY WITH ALL ON-POINT Issued by: Date
SO CER ULATIONS.
Re-roofs
ig.utxw ApplicanVConlreclor ate
HAZARDOUS MATERIALS DISCLOSURE Type Of Roof
W I the applicant or future building occupant store or handle haraNuus material
u defiad by the Cupertino Municipal Code,Chapwr 9.12,and the Health end Safety
Code,Sefton 25532(e)? All roofs shall be inspected prior to any roofing material being installed.
C]Yet
Will the applicant or f tum Wilding occupant use equipment or device which If a roof is installed without first obtaining an inspection,I agree to remove
it havani air contaminants ss dc0ncd by the Bay Area Air Quality Management all new materials for inspection.
lwlct?
Dyes I �o
Ihaveread the hevallouss25505, 533ande5534.1uncerChapter
rstand95 of Ne Califor- e //S \ /l D� O
ria Hcalthgs Sefny Codc,Sectioa25303.25533 and2553a.1 understand dw if the Wilding '/V��e.NVNAV/i�s✓f/ ✓X„I
it not currently new a want,thm it is my responsibility k nntry the recti t of the
re iremenuwhich most hemet priortoissuanceofaCertifwal�oF c� Signature o Applicant Dale
_ $N(3uR PASV MAI2 , All roof coverings to be Class"B" or better
Owner or ambokf agent Date
Community Development Department
Building Division
City of Cupertino
10300 Torre Avenue
Telephone: (408)777-3228
CITY OF Fax: (408) 777-3333
C U PE�T I N A
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 steps are
required:
1) Pre-inspection and/or tear off approval.
• 2) In-progress inspection approval.
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 abovye�stated policy on re-roofing.
Homeowner's Name: �KW r`►' T lA�p�7UMf( ��ll
Job Site Address: Z0'1g2— PPtZgVF Avco
Roofing Company Name:
A plicant's Signature: tyywvw{ /� Date: 02 �43
Greg eel
Building Official
Revised 1/30/03
Printed on Recycled Paper
OWNER-BUILDER VERIFICATION
1. (Check one) I or my 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 L k
If B or C is checked,com lete 2 or 3 belo FEB 13 2003
B
2. A state licensed contractor will be hired to do:'
A. _ All of the work
B. _ A portion of the work(complete section be ow)
Contractor Address/City Phone # State License # 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
performed
. .....................................................................................................................................................................................
I declare under penalty of perjury that the above is true and correct. I have read and understand the
Owner-Builder Inform�ation(reverse side).
Property Owner's SignaturG
'ti 1 \ O 3 d36: co 60
,41e(
Address-( Per t
Any changes to the information provided on this form shall be submitted to the City of Cupertino Build
Department.