06070055 CITY OF CUPERTINO3.�, e;I
OU1LDIN(A)l VISION PERMIT _CON.TR,&MR INFORMATION
BUILDING ADDRESS: SMSA ROOFING "'Rm"NDU6070055
7463 BOLLINGER RD
OWNERS NAME PERMIT LSIIE DATE
DEVINE TRUST ANITA THE 1900 DOBBI
NE SANTIARY NO. CONTROL NO.
(408) 254-7904
ARCH CDENGINUR: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
I� (� C= 0
3too LICENSED CONTRACTORS DECLARATION lob Description
to iC I hvcby.rinmo"1 am li o--i unacr Pl or cbaper 9(com n ng
^
Nth Sad.7000)of Dlvlabn 3 afibc Budnat anA Nar.W cocodc.and my 1r is
< itrmrcamart-If � � J REMOVING ONE LAYER OF WOOD SHAKE, REPLACING
°YOivWITH STEEL TILE
t- Dpe Covrum _
ARCHr7ECfS DECLARATn
n•
f 1 mmnpa«I my plaahall hr uYd u rubric rump
JyU
r u Liwcd Pmfadoul
'03 OWNER-BUILDER DECLARATION
f 1 brmby arum that 11. cacmp from Nc Cmuanafa :Aa Y Law far me
_p o 'Ibich ng wan.(Sndod 701.5.I.3,Bu.. and P dof mon eodc:Mychy«cavy
5$� wbicA rtgwra a permit m conunc3 alxr.Ynpve,demollah,m mpdr my pNpvm
_is^ priognii iauttu.alw rtywm Ne.ppl�nlr«wch lermil io fJe.wtlYd n+lo^ml
Flo Nu h:uheenmdpt ttodopmvidadiofdYContract«'+Li .lawCUPI.9 Sq.FL Floor Arearil
alu�t>k75000
2 (cmunanng with Sento 7000)9 Dividm 3 or do Bod.aN Pmrmlou Codas
dit be h e,ump thPefmn tri the lad.fa do a lged,....,plm.My vlolnlm of
S<Non 7071_5 by any appB fog a primp vbjccu me appl tto a6A!PwyN APN NumberOccu
ant came Nan fire hbtdmd ddin WWI. 35923023 . 00 ju _ 14?
?Q06Pane Y Type
yAownerorthe ba amsy,ogmy moployea whhw•gnu Nelr sole caopmvdm,
wBi do me r
wok and he
tnucmre4mtidYndCE ogoRemd 1ora.kst�7014,Huai. GG �pp 7A�
and Profodona cock The Co,t.UW.Llame lawn n saw donot apply an of ��du:' N
Property wbo build+m ivpmtet Nveon-and windmsauch wort hiduelf«Nmugh hi.
B
awn cmplaym.proNded Nat vch impimemrnu art not wv4tded ogaflemt fu ogle n,
bovmc.dY kidding og hdpoaemrm is mid wBMn am max of cumpkdm.drt ovner-
bu1Mer win hate Ne boNen of pmving that k dM not boiid ar imp fm ptvpom of
,algia
0 L a moan Of the"Pa'ly.am eadalwcly coonclot with Bmucd mnbtrim to
emuwet do project(sec.7044.Bulnm add Pmfeuiogn Cade)The Cdo a s U
cmue lard cat apply n aoa or property who boida w Impr abamoo.and.
who cmruu to,such pmjecu whh a cmww.,(s)Bathed purwa•ot to Ne Coetvmofa
Lie..«law.
O 1a...mPtuMu Sac ,B&PC for this
Oweer Oto,
WG iKFRs COMPENSATION DECLARATION
1 kmby alllrm mWcr Peulty 0( dory on o(dY fid n&dedtoa mc
flava and win malnuln•Cr fiau,ofCog mnYIf-Wort fm Wa -Cm*co-
adm,a pm,v for by Sudan 37W a de labor Cada,for the Pori rt¢of the
work fm which this pvmR is i=1
0 I bat add in mdmain WdM .compcos".Idvo .a oapdred by Scctlan
J7(10 of Ne lata code.fog WpeRmtuncodf do wort rm which Nis prmltd� .. .
Mywortef CompevwlmI�' rartier sod Policy number are: _ _
C. .. �� M327 Parity Na:
CERTIFICATE OF EXEMPTION FROM WORKERS '
COMPENSATION INSURANCE
(This audm and cat be caopicW IrW p hV fo,sec hvMrM don.(Sion)
or Inv.)
I mdfv Nat N do pvfmtudee of Ne wrt f«whi[h LLu remit lsRrd,1113111.
cmpbofCaiiertm b any vuomrmanbecam aubjutn NeWMva'Compevalm .
lain of Cdiforvia DaY
NOTICE TO APPLICANT.If.afar mating dda CcrliRcuc of E.cmnpdm,you+hood
buovc mbfect
to ft Wm .C N.tlnn pm ttiou al Ne labs Code,you mow
.J O formwlN rya N
comply with aueh pvW. u pit"I be domed rtwked.
Z� CONMLICrION LENDING AGENCY
'rr IMmbY.Rm
by,both la a co.dm wiling apocy for do perfarmada of
a > the wort fog whkh dila Pumll b:.....n(Su.7077.Civ.C.)
GQ LaodoY Name '
a Z IsMeraAMn.. .
U O 1 .ay that I tiK and that.ppLicuion and pu,that Ne+bora Infmnplm is
IyF cot l agree to comply with at city and county mNtunna.nd tine laws mluintID
OU building covuuct,m,end hcmhy auNanrc MpWMUt ortbu city to C wr upon thc
W +have-mendamd property ror irapccdan pur�
(We).,.to vw,indemnify and tamp ham Ne City of Co rboo+{tical
tih lnbilida,judgmcm;caw.Mcorm¢+which may In an y.,urncagdat urd CRY
UZ in eovegan'e of Sof Nu pemiL
APPLIC UN STA DS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOUR�RR." ONS`
Re-roofs
HAZARUS MATERIALS DISCLOSURE D�
DOType of Roof
WIR the.ppLiont og faoge hdldlog ocoup.pat og haddlc havrdaut mua'vl
as Oeflnod by the Cupm yo MoolcIN Codc.C 'W 9.12.and do FkdN aril Safmy
Code.Saedm 255324)7 All roofs shall be inspected prior to any roofing material being installed.
DYaNa
bu0didgoavpam « If a roof is installed without firs[obtaining an inspection,I agree to remove
Will Nc.ppliam or run. Mquipmmtwbkh
emit hvudooa dr conumirunu a ticnrN by the Bay Arta Air QWlly Maoagcmcm allnew materials for inspection.
Dw kR
DYa � �Nu
I baa and Ne htardan manrub mquhmoaa.tadrr Clyverb.95 of Ne Cahfog-
maHolth&Sofa, Sa+iwu 15505.25533 and 25531.1 oodc=nd dmlfdc uiktieg
dLea oml-j�.Ira
Nu 4 h my rtapmdbilhy n mdfy Ne o 'ache
.1. ' -• rctpriornR—tuccaf.C=fxcaicorocuppY]. Signature of Applicant Date
7`//-� All roof coverings to be Class "B"or better
¢rot Date
CITY OF CUPERTINO
1 of 1 PERMIT RECEIPT OPERATOR: kiersaw
COPY # 3
Sec: Twp: Rng: Sub: Blk: Lot:
APN . . . . . . . . : 35923023.00
DATE ISSUED. . . . . . . : 07/11/2006
RECEIPT #. . . . . . . . . : 35204
REFERENCE IO # . . . : 06070055
SITE ADDRESS . . . . . : 7463 BOLLINGER RD
SUBDIVISION . . . . . . .
CITY . . . . . . . . . . . . . : CUPERTINO
IMPACT AREA . . . . . . .
OWNER . . . . . . . . . . . . : DEVINE TRUST ANITA THE
ADDRESS . . . . . . . . . . :
CITY/STATE/ZIP . . . : CUPERTINO CA, 95014-4332
RECEIVED FROM . . . . : MELVIN STEPHENS
CONTRACTOR . . . . . . . : GRAEME BLACKBURN LIC # 27125
COMPANY . . . . . . . . . . : SMS ROOFING
ADDRESS . . . . . . . . . . : 1900 DOBBIN DR
CITY/STATE/ZIP . . . : SAN JOSE, CA 95133
TELEPHONE . . . . . . . . : (408)254-7904
OE ID UNIT QUANTITY AMOUNT PD-TO-DT THIS REC NEW BAL
______ _____________ __________ __________ __________ __________ __________
BPERMFEE VALUATION 15, 000.00 223.56 0.00 223 .56 0.00
BSEISMICRE VALUATION 15, 000.00 1.50 0.00 1.50 0.00
__________ __________ __________ ----------
TOTAL PERMIT 225.06 0.00 225.06 0.00
METHOD OF PAYMENT AMOUNT NUMBER
_________________ ____________ __________________
OTHER 225.06 VISA
TOTAL RECEIPT 225.06
•
Co--%-`L
Lu-v 0D55
Pa
CITY OF CUPERTINO
REROOF
• 'CUPERTINO PERMIT APPLICATION FORM
APN# 35q ._ a3-oq' ;> Date')/ . 6
Building Address:
q -3
Owner's Name: )� Phone#:
#QVLJ L/C ' a L (53 — lJ�?6
Contractor — License#:
PC, C F S
Con t: Cupertino Business License#:
lig - 4a � ids
Type of Roof Covering:
Existing: Proposed:
Cl Built-Up Roof ❑ Built-Up roof
❑ Asphalt Shingles ❑ Asphalt Shingles
.V Wood Shakes ❑ Wood Shakes
❑ Wood Shingles ❑ Wood Shingles
❑ Other(Specify) ,k' Other(Specify) I t-C f W s{"fitzl 4 ,'( -ef
Number of existing coverings Qr Provide I.C.B.O.ReportN 1'7S-y
B' To be Removed ❑ Provide Mfgr.Installation Specs.
I Have Read, Understand and Will Comply With Cu ertino's Tear Off Policy: 11
Job Description. I I
• a . t . om-Q t r do .K W � I S f l
Residential Commercial ❑
Fire Zone: Yes ❑ No Confirmed with Planning Dept. if
there are an restrictions: Q
Cost of Project: Type of Construction: Occupancy group:
16"o
Qty. if
Applicable Fee ID Fee Description Fee Group
BPERMFEE Bldg Permit Fees BUILDING
BENERGY Energy BUILDING
BSEISMICRE Seismic Fee Res BUILDING
BSEISMICOM Seismic Commercial BUILDING
BPLANCHK Plan Check Fee BUILDING
BUSLIC Business License BUILDING