Loading...
01100103 (2) 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. t� O0ZO ARCHITEC E-NGINEF.R: BUILDING PERMIT INFO kL"m- BLDG ELECT PLUMB MF.CH ao u u �yzz y 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 y 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 '