01100103 CITY
OF NG DIIVC 'ISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19251 PHIL LANE DAVE SMITH ROOFING SS�� 01100103
o pAr.ILLARD 1052 KELLY DR A10c18/ 2001
PHONE: (408) 973-9427 SANITARY NO. CONTROL NO.
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O0ZO ARCHITEC E-NGINEF.R: BUILDING PERMIT INFO
kL"m- BLDG ELECT PLUMB MF.CH
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S M Z LICENSED CONTRACTOR'S DECLARATION Job Description
1hereby 700firm.wtIam liansed vrovnronssionsCChapter 9(iommerming RER00F.
I•Zi--,C� will Section]INIO)of Diviaion3of the Business and Professions Code.antl my licenu
;s,ES ixinrwlra ande�t,39 a« —,5 4t 1 T/O COMP. , INSTALL 30 YR. COMP.
:=w a License Cress
7 3 ta,y Dao I n - t A -u1 Co.,,
ARCHITECT DECLARATIO
u O a, 1 undennnd my plans shall be used as public records
3.>
I i O O Licensed Professional
OWNER-BUILDER DECLARATION
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1 hereby affirm mm I am internal from the Contractor's License Law for the
Cies D following .(Section]oBusiness adeCode:Any my stcounty
which requires
apant t construct, Iter,improve,demolish,
or rtpi r any nmcwre
3$ ..prion t e,,alw q sihe PPlicem fwaucM1 permino Blea ergred at9erMnr, _ -. __ .___ _ __._ - _ _
WmheeArsnxd pun Mngih' p msiom of the Convenors Lcnrse Lew(CM1eptcr9 Sq.-Ft Floor•A1'ea t,( e Valuation
"o
—an 8 .m Swt onJWO) fD' inon lotthe Bus(neu rad PrPfGssionx Cock) CONTE,'.a. Lt?xa i.,<r {J 1 .
or that he is exempt therefrom vnd the basis for the alleg cxemptlw. y nolauon
of Section 703 t,5 by any applicam for a Isrmit subjwn the applicam m e civil penalty
of not foe Nam five wndred dollars(SSW). APN Number •t :l a.l Occupancy Type
❑I,as owner of the Propenyw my employees with was"as weir sole compen=,ron, 305 - FRAME
-will do the work:and the stricture is not intended or freed far sale(sec.7044,' 3 O7 - INSULAT
'Business and Profession Code:The Contractors License Law docs not apply to an wired Inspections ,
owner property Who builds or improve:thereon,and who does such work himself 601 - ROOF TEAR OFF
ar thorough his own employerrt or provided that such improvements anot intended
. thoroughthorough
offered sale:If,hiawe.ar,the wilding a improvement is sold withiir and yam of - 602 = ROOF PLYWOOD NAIL.- ._. .... .. . _- .... . _..
ompleti(nf the owner-builder will have the burden of proving that he did not build or 603 '- ROOF BATTENS '
improve purpose n t
_"_..__.-. _ ROOF IN-PROGRESS
❑1,as owrcr of ore limpets.mo eulusivNy contracting with liarued contrenon to_
_ convect the project(Sec.7W,Business and Professions Coda:)The Contmnar's P; I• .
License Law docs nw apply to an owner of proper who builds or improves thereon,
_and.who.contracts for such project with is contractors)licensed pursuant to the. _ ._ . . _ .. .._.. .. _. - .. .
Contractor's License Law.
_ ❑l am exempt under See "`t .B&PC fm this eawn
Ownci" Date r
. WORKER'S COMPENSATION DECLARATION r C VI I�e A LCa D
1 hereby vffirm under penalty of perjury one of the following declarations: , K G
0 I have and will maintain v Certificate of Consent to self-imme for Warkees AI O I I 0 5 2001 L D O'1
Compensation.an; provided for by Section 3700 of the Labor Code, for du NOV V I
performance of the work for which this pmoit is issued.
❑l have and wili'nmintain Workers Comptimu ion mxurance,'aa required by Section BUILDING
37M 61 the Labor Code;far the performance of the work for which Nis permiiis
issued:MY Waders Compensnion lmumnce Cartier end Polity number am:
n.. _ ... ...e.-... ..-.. . ... .w
• vmtt 5144 lry No' IIC "I L�3^OI n ' SSs •�F•:"p N •s t'�1.01 a n.AI s'll':.r<.••t _
Ii CERTIFICATION OF,EXEMPTION FRGM WORK_RSI',• r'n r fS.i• = �A' •.`t x ^ 'tea 11. �' t
r._ c •' •. COMPENSATION INSURANCE". . •:�._ __..-._..._ — __________.___.-_.
�f."t°(This action ncednoi be completed if rhe pertnir is for ane bonded dollen •lti I.'.p -- 11C. ;�1'1 •-, '1 I;.
(SIM)or lcsxJ. .. _.
,I empl that In the n in anynIa bol Ile work for which this permit a issued;l „, „ I;', i s'•r`r 1" .. ,
s daiscot employ any person o any manner so ss io become wbjem to the Woden'
Amficnshlian Lown of Cali[omia;Dole
Applicant. ' .p, .. .... i _ . .. . . . .
NOTICE TO APPLICANT:If.after making this Certificate of Exemption.you should
hm
ceme bjcconme Wartime.Compensation provisions of Ne labor Code.you mon
Q Q fonhwith comply with such provisions or this permit shall be domed revoked.
F " ^" •CONSTRUCTION LENDING AGENCY' "' -- - l •
•'I beseby afliim that there is a construction lading agency for the per r emance
W. c the, kfo hich th pemit is issued lsec.309].Ci v.CJ
Land e N
�. Unders Address' r _ r
U-0 ,a I certify that 1 have read thisapplicationend slam that the above information is
Lia:.t••, correct,I agree to comply with all city and county ordinances and state laws relining
Q fJ toboilding construction.and hdreby arthoom repmsenntives ofthis city toemerupot.
r•-Lr] the above-mentioned propend for inspection purposes.. ,
(Wel.M.to save,indemnify expenses
and keep hamdcn the City of Cupertino st r rd
Fw Vi liabilitiu,judgments,costs and expenses which may in any way acetate against said
/�Cd�tYy quence of ih<Bmming of thlx permii'„ '
�SPk CBI e'UNDERSOTANOSAND WILL'COMPLY WITH'ALLL NON-POINT ' Issued by: Date �+
Io—i )
Signature of Apprcainvontriaor: - Data Re-roofs
11
HAZARDOUS MATERIALS DISCLOSURE
will Bre ambcmt w f tiro bonding ac pant n or narwli iuwdoax minimal Type of Roof - _._ ... .. _.. . _.
as defined by the Cuiar o Munralxf Code Chapter912.and Ne Health tad Safety `•. Is ..,a.. - •:..,. ] .1.,� s• r.. �.(
Code S et on 255J21e1 ss ' Its
i;'t. `�' `" All roofs shall be inspected prior to any-roofing material bein Installed _
- OYa• .yrr a:r r g .
.boar ffieayplmntor future building ottapantuse equipmentor devices which If a roof is installedwithout first obtaining an inspection;I'agree•to remove
emit ha>.vLoda air contaminants as defined by Ne Bay Area Air Quality Management
District? all new materials for inspection.• Applicant understands and will comply with -
Els Yet all non-point source regulations:
I have mad the h zmdo. r n Is recurrent a under Chapher 695 of the i
Calif in dos 5 f ur Cod have
ion 25505 255JJ d 25574 1 ndentand N e 1 7 '�^^��
'.if th building dges notcurrentlyh et t-0 t t stay- po bdiry to notify the ( Vi- 1 p,^' 6
of the eyvi.. ix x hich must be met p r to issuance f a Certificate of \f
r Sri °GuP'n`y - j p:. l �_ Signature of Applicant Date -.
1 0l
'd•;._ " r aamo�d�ed agent,— - Daie All roof coverings to be Class "B"of better.
F± - OFFICE '