01020023 (2) 4` CITY OF CUPERTINOBUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS:. . . • - - PERMIT NO
1196 CRESTLINE DR DAVE' SMITH ROOFING ' I . 010200223
OWNER'S NAME: - _ - APPLICATION SUB DAP I.
HABERLE HELGA ' A 1052 KELLY DR' 02/06/2001
ONE: . SANITARY NO, CONTROL NO. `
(408) 973-9427
• n O O ARCHITEC'VENGINEERt BUILDING PERMI r INFO'
E BLDG ELECT PLUMB MIiCH
y Z
OZd=ws+' lhereb,.Mmthmloml oaJundlrpm�ansofcluror9(commecin, , " '. Job Description -
17=Fto with Section BEB of Division 3 of the Business and Professions Gddemdmy license
— i`infnurnree:n ( n �I Z t�(u =v TEAR—OFF, ROOF R INSTALL ELK ROOFING
¢ Liccn.m Css
W nom c cnmmnor -
< ARCHITGCf'S IIECLAR ON
'CQOl IunJentand my plans be teed m Public¢rords • ".f '
Y
L. O Licensed l'ndessinnal -
a. OWNE R-BUILDER DECLARATION
GG11 I herchy corm,that 1 am emend from the Contmemr's License Law for the
AuLlowh z< which mg reawa pSedint 7o3L5.Busitese and Pimdemolish.
h.or Any city orewnre
FG wh h requires pi t construct: h improve, Icmfh p' any structure
3m PInion,t t co 1 :m pl li of the
slip 'n II seL J,nmmea .
(com 1 thPursuant II p n flh t mocha,Business I' nr fe on pter9 S Ft:FIOorArea ,
}c gnat he is exem Sttt on 7IXNBd the s is o uftM legdeand Professions vi Corel q' Valuation
or Sec io 7 exempt,hcrcfvnd and the basis for the allege)exempnioo Any violation 1$7200
of Sermon 9011.5 by any nppltcnm for n permit subjects the applicant,o m civil penal,
of nm more 11 Eve I.mcost dollar,051101 y ., .APN Number Occupancy Type
n2
°1,as owner nfthe ani
s ra nay employees wide doges as their sole 7(M
-L (!. 00
will ne the work,anJlhe ose Th C not Char, a or License
Law for sale(Sec.9111E
Business and rly Who
Cose o The emnradn,y.keds o d Ansa nor apply m an Required Inspections
owner of pmparw Whe builds ur i sided t marcor,and ve does such work intended
or
or eredfo sal own employee., thauidin that men hnpmvemenkdas not In ender or x 305 '— FRAME
cout to for sale.If.however,the W ilding e t i rdi pens is sold within one year of
improve
thealsomfBedlam will have be Wmenmprnvfng oda,he ria nod nnaa or 307 — INSULATION '
nnprove for p,upnae nfaole.} 601 — ROOF TEAR 'OFF -
°1,as owner A the prolsoly,am oxchrouly canlruciing whh licensed comments to, - -
construct me project(see.7044.Business and Profession,Cale:)The Contractor's' 602 ROOF PLYWOOD- NAIL
License Law ddmx not a v an owner a
apply fpvlenYwho Wilds or improves thereon,
the
and who amdmens La man projects with'a admnmenls)liccrettl punuum to mo '603 — ROOF B'RTTENS
El I oro exempt`ande See ,u&Pc mrmi,m„on , ' 604 ROOF IN—PROGRESS -
Owner Date _ • ,FAN
WORKER'S COMilENSAT1ON DECLARATION, /� ILeD, )
I herchy of en tmacr fuoud y of perjury mm o�tbe follnwin,decluclinm: I~
II have and rill maintain a Cenifieme of Consent to self.insum for Worker's JAN O 3 q
'nnpeneatinn, as.provided for by Section 3700 of the [..her Code, far the >
porforrnann•of the work fin owhich chis permit in rested. 200'f
°1 have and will maintain Worker's Compensation lasumnee,as rtyui ed by Sechan LDINCj '
17011 of me Labor Cole,for the performance of Ne work for which fermi,pei,is -
issued.My Worker's Comiscicnsmion law alaC caricr'md Policy number are ,
Currier: S liC 1_vissr)-_Pal icy No.::. s •.
CERTIFICATIGN OF EXI?MPTION FROM WORKERS' r. u
COMPHNSA'I'ION INSURANCE -
IThia.mcdion avert n a hecnmplolW d the Ierntit is for ons in cost dolb:n _ r
IS I oo)in le".) ,.
1 cenify tha,in the performanre of the work for which this permit is isauM,1 '
.ihall not employ any person in any manner so as m become subject to the Workers'
Co,uPprxulion Laws of Calilomir.Dam 1 "
Applicant
NOrICETOAYPLICANI':If.after making his Cerificade of Exunt ion,you should
Ohcnme whjcct m the Wurlcr's Compensation Prov s ons of the LaWr Cdxle,yon mon
forhwim comply with such prrwision.s or this permit shall be Jesmed revoked -
F4 CONST RUCTION LENDINGAGF,NCY - -
1 hereby affirm that there is a construction lending agency for the perfommnce -
w of the work for which his occur,is issue)(Sec.3097,Civ.C.) ,
E Lender's Name -
�J' z Lrai Add,,,,
,V I cenify that l have read this.,heation.,,itfo
s,atnthmthe move innnmiun is '
Gat E.d cored.I move a,comply with all city and county on inancee and slate laws retain,
[) to building eonswaion,and hereby andante representatives of this city no enter upon ,
�+ W the uhnvammulnnsJ pmpndy for nepccdoo pulpnncs.
[r 6t (We)ugreco,a:r,indemnifyand keephandees the Chyol'Ca,cmao vguin,t s - w
V1 liabilities,judgment,coos and expenses which may in any way oceve against said +
V z City in consequence ofine,mating of this permit.
' LICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
q 'GULAI Nsr Issued by: Date
,S . c of App icon 'ommner' Date Re-roofs -
HAZARDOUSMATERIALSDISCLOSURE.
Will he applicant or future M'ildingoccupnm score or handle homNnu,nnorial Type of Roof,
us delLmd by the Cupen lea Municipal Code Chum”0.12,and rod;Ilealfh nail Sur c, s a
Code,See an 25532oll '
❑re. - El No All roofs shall be inspected prior to any roofing material being installed.
Will he uppliamt or future building occupant use equipment or devices which If a roof is installed without first obtainingan itis ection, I agree to remove d
emithamolo or corcounaux as dslined by the Hay Ards An Quality Muun,emm�l p, g
,tried° all new materials for inspection. Applicant understtinds and will comply with
°Ye °•"" a n-point source regulations. Pp p y
Ili mm!the h rl materials rey t. order
rJ Ch p' 691 f,he -
Calif Health&Sd,,,C S f dr25505 5539 and 25534 J '.h nJ that '
mail does ole tlyh moa, that ill nYresponsibilityf-n tilt,the //�/�
�a t -hmillion, end. t W ,p r t issu of.C n fcae of �.✓ L�• �-s.
Dom an°, -_ 2 . U l 1 nature of Applicant - Date
Dw erorau0 nt ,- Dole All roof coverings to be Class"B" or better
OFFICE
d . I .