R-0261PERMIT R_ 0261APPLICATION FOR CITY OF CUPERTINO NUMBER
R-
INSPECTION DIVISION PERMIT EXPIRATION
PERMIT PERMIT EXPIRES IE WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
BUILDING USE
7583 Lockford Ct.
RESIDENTIA00�t COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF
NAME Nr. Mrs. H. Loucks
FIRE COVERING,
AREA CLASS
EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS 1
ADDRESS 7583 Lockford Ct.
PHONE 40$ 255-7356
TO BE REMOVED RS%II TO BE RETAINED
CONTRACTOR'S
NAME ARC Roofing Technol
TYPE OF ROOF COVERING
ADDRESS, 472 Elite
CITY & ZIP; rprise Avenue _
EXISTING
BUILT-UP ROOF
PHONE (415) 782-7916 - 370-3808
ASPHALT SHINGLES
LICENSE
NUMBER477060
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter 9 (commen-
ing with Section 7000) of Division 3 of the Business and Professions Code,
WOOD SHINGLES
and my license is in yjlI�� force and affect.
Liven C C -.ii Lie. Number 477060
JtMting
OTHER,(SRECIFY)
Date'%-2�`-Hi C.nturedR]RC
OWNER BUILDER DECLARATION
I bacehY affirm that I am exempt from the Contractor's License Law for
V
PROPOSED
s
the following reason. (Sec. 7031.5, Business and Professions Coca: Any city
whichrequires a permit to construct, altar, improve, demolish,or
rrecounty
pany structure, prior to its issuance also requires the applicant for such
BUILT-UP ROOF
Permit to file a signed statement that he is licensed pursuant to the provisions
of the Contractor's License Law (Chapter 9 (commencing with Section 7000)
m Division 3 of In. Buzinesz and Professions Coder or the, he is exempt mere"
ASPHALT SHINGLES
from and the basis for the alleged exemption. Any vlolatlon o1 S... err
7031.5 by any, applicant for a permitubjects the applicant to a civil penalty
of not ree that five hundred dollars ($51
WOOD SHAKES X�
❑ I, as r of the property. or my ampl oyeez with wages as their sole
compensation, will do me work, and the structure is not intended or offered
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
WOOD SHINGLES
Law does not apply to an owner of property who builds or improves thereon,
and who does such work himself or through his own employees, provided that
improvements a not intended o offered for sale. If, however, me
OTHER ISPECIFY)
buch
uilding or improvement is sold within one year of completion, the owner
- builder will have the burden of proving that he did not build or improve for
purpose of sate.).
PROVIDE LC.B.O. REPORT NO. -
❑ I, s of me property, a exclusively contracting vi licensed
contractors to construct the project (Sc. 7044, Business and Professions
Code: The Contractor's License Law does not apply to an owner o(Property
PROVIDE MFGR.INSTALLATION SPECS.
An. builds or improves thereon, and who contracts for such projects with a
contracto 'Is) licensed pursuant ,o the Contractor's License Law. _
❑ I am exempt under Sec. ,B.&P.C. for this
FASTENER
owner Data
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate f consent to soft insure, or a can
TYPE Nails &. Staples
a copy thereof (Sec.
I� P
of W€+�i
3800te
sompensetion
3800, Lob.
�caniliatl
Policy Np. CompenY AII�
❑ cc2ifi � Py he b wtmshed'
Ih
LENGTH 134
❑ Corti ,ac. py the ci y I n tlwision.
FEE SUMMARY
�ry�pyn
Applicant fi Y3
`CE TIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This section need not be completed if the permit Is for one hundred doh
Tars (s, em or less.)
VALUATION r
I carffy that in the performance of the work for which this permit is
-t
issued, 1 shall not employ any person in any manner so as to become subject
t0 the Workers Compensation Laws Of California.
Data Applicant
NOTICE TO APPLICANT.. _If, after making this certificate of Exemption,
PERMIT FEE
you should become subject to the Workers' Compensation provisions of the
Labor Code, you must forthwith comply with such provisions or this permit
DATE OF APPLICATION j
shall be elected revoked.
I certify that I have reed this application and state that the above informs
-
tion is correct. I agree to comply with all city and county ordinances and
3
atato laws relating to building construction, and hereby authorize represen.
9/16/85 jl
tativoz of this city 10 enter upon the above mentioned property for inspection
PERMIT VALIDATION
purposes. y p p
(We) agree save. indemnify and ken harmless the City of Cupertino
against liabilities, ' pigments, costs and expanses which may m any way accrue
s cos
s '
gain t saitl C y' nsaquancaof h granting of this permit
Al
/n/ nn � r
irign
ore of
Appllca t/ContraC Data
REQUIRED
PRE -INSPECTION
IN -PROCESS INSPECTION
FINAL INSPECTION
INSPECTIONS1
IINSPECTOR DATE
INSPECTOR DATE
INSPECTOR DATE _
i
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY