00070091 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING 5V)5'0 SUTTON PARK PL DAVE SMITH ROOFING rlalnnT N(00070091
PINER'sWIPLEY DAVID AND VIRGINIA 1052 KELLY DR APPLICAI'Il&7dAbWt1G
ONE (408) 973-9427 SANITARY NO. CONTROL No.
u D O ARCHI'niC IENGINHER: BUILDING PERO T INFO
F BLDG EUClPLUMB MLC11
y� I_"I LI IJ I_J
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S y- LICI?N t l an, i,r.,d ufOH'3 DECLARATION Job Description
Fv_u- ✓+u, 1 harhy)(I that 1 nen lic'mi,B under proviGom ul Ch Cord 9 nd mmcnurg
wishSection]IXMtlof Uivision3ofrhe Rusinms and Pmfessiom CWe,nand my liccwe' REROOF
¢ S_' h in lull limce:ud elect.
¢ )ter Cla.x_e-.7-11
3 LL node ew'IECT,sincl nen lory
C u.°4 1 toderxwnd my plans shall he u,ed as public records
we,
s p p Licensed Prole.xinnxl OW'NIiR-
HUILDIiR DECLARATION
al Ihereby affirm that 1 am exempt from the Contractor's License,Law for the
i follow'mg........Igvcllun 9131.5.Iim :mJ 11...1 . tx Code Any Illy o my
sz-a which"nor,a permit to amnow,alter.improve.demolish,or repair an, bu,mm
prior to its issm.nove. .o revenues the applicant for such pemtino file a signed statement
d%= d
It.,I,i,his, Wvnomre ,,theprwiximxxnoneComm,ntrsLi,cns,lawICIInplcro Sy. Ft. Flour Arca VAL7AW
Icommencing with Section]P(X)of Division 3 of the Business and Pralex,ions Calc)
nsr,hal IIB is exnhtpl durefrnnt and the hasis for the alleged exemption,Any violation
l'section 7031.5 by mor appBcant for o p{hrmil wlJectn the applleuo,to a,ivil penally
of not more than for hundred dollar,65IXR. AF;*t 40[_;71. 00 Occupancy Type
❑1,as owner of the propcny,or my employees with wages as their Iola aontpenwtion,
will do the work,and the structure in not intended or olfercd for sale(Sec.70y. -
ILIxinsx anal I... inns Crde,The.C.... „tux Lmel„c Law one,on,apply to an 305 — F RAhAt9uired Inspections
r of pro,eny Who hands or inspires thereon.and who does such work hintxell
�r th
nmgh his own employee.pn,,idcd that such impmvemcnts no not intended m 307 — INSULATION
uttered In, fle.11,howcvcr.,he huild'..,oI uupaov.ntelll i,nom within one year of
Icompletion,the owner-builder will hove the burden of proving that he did not huildor 601 — ROOF TEAR OFF
ntpmve Ru puToxe ofsula).
602 — ROOF PLYWOOD NAIL
❑Lasowner of the pmnny,0tha iomass esmmeing with ds:)The C norcu',
License
he Jo,%n rsppl it,a.nndnc,it amt Pmfcxxio hewer)Toeves tmreon, 603 — ROOF BATTENS
construct Law doe..ern apply u,anowner m prnp,ry who Haans m improves thereon.
and who contracts Rn such Broil with a conorcho t liveried pursamtt to the 604 — ROOF IN—P OGRESS
Co Lioensu Law.
❑I.,It c,enpt under Sec. .B Ni P C lir this Imam -
owner Dane -
WORKER'S COMPENSATION DECLARAi'ION -
I hereby still,unde, crall,of p,rjnry one of the folowing ted"Iniatx:
CC I1 1 ll maintain a Certificate fc I elfm f Worker's
C
p I no d l r 1) },I 391X1 r m 1 n ( d - ma V
pert m f thework( which II pc t issued.
❑Ill I 'll - m ' Work,-:C y , 1 : ' et, ' Jis,Seen h ,^
3](X1 of the Labor Cid,for the performance of the worts for s ch this pent , O
sited.My WWoorkeiei'.s�C�onyunsation losme tee currier Ilnd Poli,mmn err are
Ionic,:
:
Crtier:
�r�_'1 t %P Policy Nn:
CI1R'I'IFICAfION Ole i,XEMPI'[ON FROM WORKERS'
COMPENSAIION INSURANCE
milds wo,ion nm:d nm fw aomplcmd IfIIIc permil is for line hamdmd dollars
(SIM)or le".)
I unity that in the pellormancc in the work for which Nix permit is Issued,I
shall not employ any person in alit,manner so as to become wbjee m the Workers'
Compensation Laws of Cablonnia.Dare
Applicata
NOTICE TO APPLICANT:If,emir making this Connotes”of Exemption,you should
h"i IIsubject ,,,heWmonIContpcn.allon ryavixienx If he I.ahor code.ren mux,
O fonitwith comply with such provisions or this pennil shall he JcemeJ revoked.
Z I,
F" CON the.is.coNLENDI NO AGENCY
1 M1ercby Is hirm this there is a mmltmSec. lending agency for the fcrtixrmanw
w of the work mr which this permit is Isuu•J(Sec.3(19],Civ.C.)
0
L Lenders Nan" _
z landcrz Address
U 1 notify that I hoc read this upplitevtion add one Ihot the above infonuwion i,
(s F" coned.1 agree to comply with all city and county nminances and state taws reining
O U ub Ihn, :t I d hatch, ,ha p dives oflh: lYcom,upon �a���/�J/�/�•
the M t J p pend for :peck
r d
(We)agree to a c indemnify and keep fan 1 ,the C ty f. pen o against ��11
V] TaNl,cosi t,.........
n,n s -t: 1 s h 1 Y 'nnY Y bunt siJ
U Z consequence of the gmming or Ibis permil. t
APP,IC .TUNDERSTAso AND WILL COMPLY WITH ALLNON-PoINT Issuedb Date
SGO,CER TI ti. y'
MAn
Appoxvnvcnmmem Da" Re-roofs
Will the applicant o metre Wilding Novation st re or han le ha,aranux madder Type of Roof
as drained by the Cupertino Municipal code,Chapter9.12,and the Hcal,h and Solely
Code.Section 2553210)'!
0Yc, ON. All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or deices whim If a roof is installed without first obtaining an inspection, I agree to remove
ntit hazardous air commitments as defined by the Bay Area Air Quality Management
nhi,e idLingw materials for inspection. Applicant understands and will comply with
❑Yes ❑"° non po' t source
I have read nate hmardous mal,6U,r,yni...tell,under Cl,,,,,,,6o5 of IIIc
California Hicallh does Safety Code.Section, 255D y respa3J.1 understand u)runt the ^,/"'•) ,�iya Q
if lh pbutar, if a"mo currcnlly have
mit ust hal,that i,i,1, rceponsihility In notify the ( V
oc,upenl lir the rcyurc,nnnx which must be net prior In inNanCC ell a Ccrliir'ulU of
Occupancy' Signature of Applicant Date
owner orauthorbedagent Date All roof coverings to be Class"B" or better