R-6128 APPLICATION FOR clrY or cuPERrINo NUMBER R" 6128
INSPECTION DIVISION R MEXPIRATION
REROOF PERMIT I4Da� m-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
RESIDENTIAL '
COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
n Q�\{ -t.- P\C rte•-. w s Cl —
YES ndo If yes_1 Untie stand thatGass A
NAME roof assuis required.. '
NO ] Initial I.C.B.O.A
ADDRESS l� g-S �FM Cam �. C.0 Pt'-'(1T1 TJ EXISTING ROOF COVERING
PHONE 'L O NUMBER OF EXISTING COVERINGS
CONTRACT 'S 1 -
Cl�, TO BE REMOVED TO BE RETAINED a
NAME _
ADDRESS
TYPE OF ROOF COVERING
CITY s ZIP EXISTING
PHONE - BUILT-UP ROOF ❑
LICENSE
NUMBER ASPHALT SHINGLES " ❑ -
LICENSED CONTRACTORS DECLARATION
I hereby affirm bat I arrt Acensed under provielone of Chapter B(commencing with SectionWOOD SHAKES X.
70 X1)of Division 3 of the Business Meet Professions Code,and my license full Is In force and
Mact.
WOOD SHINGLES ' ❑
.Ucanee Close Llc.Number
Dale Conti CIFY) ❑
OWNER-BUILDER DECLARATION S,
I hereby all that 1 am exempt from the Contractors License Law for the
bitn.
(Sec.7031.5,Business and Professions Cotler.AM dry or county whkh reI to
construct,alter,Improve,demolish,or repair any structure,prior to its Issuancettfitt�$. l
applicant for each permit to file a signed statement that he Is licensed pursuanto
oni lC 7 etas P F ❑.
bit the ConmBdore Lice me Law Chapter B(commencing wdh Section 7000)oof th
. Business arta Proteaeiore Codes or that he is exempt Iheretr m Mrd the baIleged ASPHAL NGLES' . 71
examptlon.Any Wolatidn of Section]031.5 try arcy applicant fore permit eubjecnt to
e civil penally of not more than Ilve hundred dollen(55001.): x.
10},
as owner of the Property,or my employees with wages as their sole corrtl S y`
the Mrd the etmclure Is not Intended or offered for fele(Sec.7014,Busn
skate Code:The CoMractoes License Law does not apply to an owner of property who bullets or
improves thereon,am!who doss such work hlmseffor thrcu his own em WOOD SHINGLES
W doing or movdetl Ura ❑
ouch Improve men le are not completion,
leb n,a offered lou leer. it however,the en of pr or In that he nt
b sod withinor
yearor Purpose
of the owner-builder will have the burden of praWrg that he a'd OTHER SPECIFY ffTTll 1 1
not Wlltl or Improve for purpose of Bale.). (SPECIFY) L?
01,as owner of the property,am exdusivefy conhaclrg with licensed contractors to construct
the project(Sec.7044,Business am Professions Code:The Contractors Lbenfa Lew dose not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property whob Ilde orlmprovee thereon.and who contracts for each projects
with a cor`ncta(M licensed purer l to the oonhsdoes Ucenee Law, PROVIDE MFGR.INSTALLATION SPECS.
1 am exam under Sec. ,B&P.C.It Nle reason
Ow Dete - APPLICATION DATE VALUATION• PERMIT FEE
RKER'S COMPENSATION DEC TIOfJ
I hereby ett o pe ury one o e DI
1 have and will maenoxin a Cerlhlcate of Consent to self-insure for Workers Campensatlon, Building/-S-7
, ��
as provide)for by Section 3700 o1 the Labor Code,for the Performance of bre work for which till 1 � g,-
permll itt hareBuetl. L - 7 -
7 � QL 11 SBISmic
❑I have de.nd will mal pelinrformance
Workers f the work
for Iwhich co,co implied to I by Section 3700 of Il N+
the Labor Cotle,for the performanco of the work lar which this permll fe issued.My Workers IS J,Compansadon Insurance carrier and Polley number are: - _ notal
Carrier PclicyNo. PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.00
(This sedbn need net be completed If bre permit is for one hundred dollars($100)aleaf.) 6 r ._ �d
I certify that In the pedormMI of the work for witch Ipermit is Issued,I all not employ lll... ..///
any person In any manner so as to become subject to the Workens'Compensation Laws of call- All roofs shall be inspected prior to any roofing material being
fornix. Installed. If a roof is installed without first obtaining an
Data Appllcant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: 11,after making this Certificate of Exemption,you elmuld became Applicant understands and will comply with all non int
subject to the Workers'CompeneMtlon prmmuons of the or LabCode,you must kmhwhh comi PP P Y PD
with such provisions or this permit shall be deemed revoked. source regulations. _
I certify that I I read bile application and slate that the above Information is correct.I agree'
to compfy with all city and county otdlnertcer and stale laws relating to butldiog conehuctlon,and All roof covering be class 44 better.
hereby authorize representaftm of ihle city to enter upon the above-mentlar ad property for in-
spaclbn puToa i V
(We)agree to leve,Indemnify and keep harmless she City of Cupenlrw a ain rt Ilablllties,
judgments,scab end expenses which trey in any way accrue against asci City consequence
of t�hpe wanting of this permit. IG ATURE F APPLICANT AT
PRE-INSPECTION: PLYWOOD: IN-P
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION:' BATTENS: FINAL
INSP. DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY '