00060110 (2) clTOlo�G DIGSION CONTRACTOR INFORMATION:
PERMIT.
BUILDING ADDRESS: PERMIT NO.
OWNER'S:,t�255 VISTA CT WAGNER ROOFING CONTR 112TP0fY9r"TP✓e00060110
]ONE O' NEILL THOMAS L AND CARO A 1'2242 SARATOGR—SUNN V'pL'^^�'"Ftfl06/18'PrL"0, rr(tD
z% ARCHITECDENGINCER: BUILDING PERMIT INFO
0 0 (408) 777-8331. BLDG a.ucr rwnm au:clt
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SN" LICENll aali"a,cdl ale, "ECLlLitITp Job Description
0 y C hereby u0....mal am IianwJ under provixlonv Lit IT 9lucmmenc'inb
wt H w will,Select 17000)In Diellon 30f 1111 Bice,rind Pude„inn,Codv.lmd m hams`
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ARCHITECT'S DECLARATION / REROOF TO PLYWOOD
j I undemtand my plan..nal]ne used,,.public recons
w n ce�O Licensed 1'mfessional
ce thatOWNER-BUILDERcon
or he CoA'rION
m m 1 hereby.(fele that nm.Dana, ,and Pr Cant n,Col Licat-c a,c Law for the
z a which
re require,
a.(Section](131.5.Buxinees and Ymfcxxinnx Cmlo.Any dry of Ls
a, carts y p 'n t plat, p I I;xl p ' Y.hmumm
e. pec I. II applicantl IP n IIsigned. 'l cent
(comb ..it prisoner,il Ihcpl n ,I it.Conarataor,I I 'mm,Com) Sq. Ft. Floor Area Valuation
latmmcnuag ramp Section]Ohba of e b sis 3 of he Emilie,dee iol PmfAn ono halm
or that he is exempt mhercfmnranJ the basis for the alleged cx applicant
In Acv viELL
of snhimn N315 by any applicant d ll Iirr a pcemi'subjean the applitmnl In u civil penalty
m not more lead Eve hundred amara($s(w). APN Number OcVpjtt?yD"&pe
01, f,hc proper., Y ermilit,ecl,with .ge their sole emopereadic.,
will d nth k d rh t t 9"c"I"velared
d ff rcJ for. l (s ](Na,
Ells dPr bra a, I J t poly In an31625028. OtGcquircd Inspections
w I p Rry Wh h IJ J h d h k it mselfortl gl Iply P tp c , t' m Iedor'
dIe Ito vale.If,hrra ( 6 ',sold vlahinom yd,r of
nnplehon,the ovocnhudner will have the humeri lensing mm he did not hu ld nr 305 — FRAME
amprwc for implore'It Irle.).
❑Laeowner ofjec P(Sec.7 come olmes%annnrzcring withlicenced Contractor"
he
307 — INSULATION
Lamm�seem w oejeno'sew,7toanBade,andPmrehobcao:)me v%therrr's 601 — ROOF TEAR OFF
id'hlawtractf apply man owner of pmpeny aso,ulice aed pursuant the I
and rano tmmmems liar seen pmgenl»;lin a'anrmema.o licensed pa dant tu me 602 '— ROOF PLYWOOD NAIL
01a
Contractor's`'tend` See I 603 — ROOF BATTENS
❑1 am exempt under Sec .n Nr 1'C for this reason
Owner Date 604 — ROOF IN—PROGRESS
WORKER'S COMPENSAI ON DECLARATION
40001 hereby mylin.under penally of perjury one of me following de,licroo.,
I have and will maintain f Cbyificate of Consent m Lal&inert de Work the
Complained o, as provided for ,y Sterman 3]W nl the Labor Cade, for the
peRnnnanm of the and for which this permit is issued. '
❑1 have and will maintain ter
the r.fomance of t eworkf as hick cd,permit
"am of the Lal*o Cale,lar the perforrance c of the work for which this permit is /
LeueJ,My Worker'.Cn.;npL/e�nJfxm��iun//inwrance'cr•ie'r,:mel policy nnumlwn/a^r�c:
Gcrricn _l.Y�J/M.p_Policy N,,:(�a.[..lJ'Op/3/0 O A
CERT 11TIC TION Oh EXEMPTION FROM WORKERS' J
COMPENSATION INSURANCE
(This section neer)len be completed if the wort i,for one hundred dollar.
I1I00)or lex`_)
I celery that in the perfnmrnnee of the work Pat whish this permit is i....d,I
shall not employ any pcnon in any manner so us to became subject'o the Workers•
Cnmpcmmiun Law.of Call untiu.[)aid
Applicant
NOI ICE FO ArPLICAN'Is 11.unur mating this Ccmfiatm of Exemption,you shordd _
heconm Indicaac file W..kcr'x Cnm. vafioa,rovhi n o1'till Latin Codc,yon 1111
Q O l itnhwim'nattily with nueh al"imon,or this penon,hall he donned revoked.
F V) CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is a d mmwciam lending agency for The performance
of the work for which this permit is issued(Sec.3097.Ci,C.)
S Q Li ndcr'.Name _
z Lender's Address
V 1`life than I have read rni,.))miction and mum that'Beltsville information ix
a '
W (ti com ,.I agree ma comply with all city Land county ordinances and state laws refuting "
Q [) nr huddingmmmmainn.and hctchy nuthonee reprexenunivesof if mercer neon
he al,ove.memr�ored mopery ler inxparmn parpoeex.
(we)agatenscot,i Lanrexc ata keephano,infle,oto city a,,rmcrmo agded
U z liabilities,pdgmcnme,core and h Rowi which cony in any war acral again,m nail
C.7 Z City in ANT Uence R the Fronting of this permit.
APPLICANTU DER. NDSA WI COMPLY WITH ALL NON-POINT Issued IT Date
ER' l
Its q �6 mg y
.Signam ApPlicanVCnmmnnr V fc fL Re-rOOfs '
hIAlAHDUUS, F.HIA,7,) l SU HP
Will the applicant or future building acuhandle halsoci mtaterial Type of Roof
ax defined by We Cupertio Municipal Code,Chand the health and Snkty
Cute,Section 255320)'!
❑Ye, 0N All roofs shall be inspected prior to any roofing material being installed.
WaldtettppheammorfotumwEdingor,if,mtuse c,m,aremdevice, hill If a roof is installed without first obtaining an inspection, I agree to remove
•ail haeardom ler camantinnnts as defired by the Bay Area Air Quality Management
Akdricr. all new materials for inspection. Applicant undersamds and will comply with
ole, 0N all non-point source regulations.
I have need the hwardnus materials re'yuimmeml under Chapter 6.95 of the
Califomip EcdmB&Saba,C,de,Sections 255115,25533 and 25534,l understand mho'
if the building does not currently have a tenant,that it is my rcxrymnibit y Io nmify the
cutin.1'he ce'rocnmm,which mux,be mel prier It,iaabce of a Ccnifictc o
Oeeupuney.
Si a[ur of-Applicant wee
ownmmnamoaa'd,gam Dam All too coverings to be Class "B"or better