R-0129 PERMIT R_ 012
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APPLICATION FOR ' CITY OF CUO'PERTINNUMBER J
REROOF PERMIT INSPECTION DIVISION PERMIT EXPIRATION
PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
V
180 DAYS FROM LAST CALLED INSPECTION.
y
BUILDING/ADDRESS .BUILDING USE
RESIDENTIAL Pill COMMERCIAL OTHER
OWNER'S s I
/� A_,i ®DO J HAZARDOUS ROOF
NAME FIRE COVERING
AREA CLASS
ADDRESS EXISTING ROOF COVERING
1 PHONE NUMBER OF EXISTING COVERINGS /
CONTRACT R'S �
TO BE REMOVED TO BE RETAINED
NAME �r ��" f /Gp If/Glr 5 TYPE OF ROOF COVERING
ADDRESS, �eUt /72.� f ,(jp�.�j( 9El'Dl / EXISTING
CITY&ZIP
PHONE1Z' BUILT-UP ROOF
l
LICENSE ASPHALT SHINGLES
NUMBER WOOD SHAKES K
L I CENSED CONTRACTORS DECLARATION
1 hereby affirm that I am licensed under provisions of Chapter 9(complain
ting with Section 7000) of Division 3 of the Business and Professions code. WOOD SHINGLES
and in Raensa is y,O l Lip and affect. 3�s, p.
License lass ( 3 a Lic.Number /.s 0
Data - iZ=�.� C.m'is[p.La f OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
I hereby affirm me, I am exempt from the Contractor's License Low for PROPOSED '
,de following reason. (Sec. 7031.5, Business and Professions Code: Any city
orunty which requires a permit to construct, alter, improve, demol'mh,or
repair any structure, Prior to its issuance, also requires the applieant for sgrh BUILT-UP ROOF
permit to file a signed statement that he is licensed pursuant tome provisions
o, tb0 Contractor's License Law (Chapter 9 (commencing mencg with Section 7000)
of Division 3 of the Business and Professions Code)or that he is exempt there .ASPHALT SHINGLES
from and the basis for the alleged exemption. Any violation of Section
J 7031.5 by any,applicant for a permitubjects the applicant,o a civil penalty
into..,.,` of notre that five hundred dollars(SSoo) .1: WOOD SHAKES �.
❑ I,a r of the property.or my employees with wages as their solo
compensation,will do the work, and the structure is not intended or offeree WOOD SHINGLES
for sale (Sec. 7044, Business and Professions Code: The Contractor's License
Law does n01 apply ,o an Owner of Property who builds Or improves thereon,
and who does such work himself or through his own employees,Provided that
such improvements are not Intended or offered for sale. If, however, the OTHER (SPECIFY)
build i no or improvement is sold within one year o1 completion, the owner
builder will have the burden of proving that he did not build or improve for
Putrid.of sale.). PROVIDE I.C.B.O. REPORT NO.
❑ I, as owner of the property, am exclusively contracting with licensed
contractors to construct the project (Sac. 7044, Business and Professions
Code: ThaContactorsLicense Law does not apply toanowner ofproperty PROVIDE MFGR. INSTALLATION SPECS.
Who bu'lits
or improves thereon, and who contracts,or such projects with a
contractors) licensed pursuant to the Contractor's License Law.
❑ 1 am ax top, g,der See. ,S.&P.C.for Nis FASTENER
owe her Date
WORKERS'COMPENSATION NDECLARATION & � 5� 6e
I hereby affirm at l have a certificate f consentsent to to seainspre,or her. TYPE
,fileV
a of or Comp on� jr a certified copy thereof(Sec.
3800,La i //1
Policy N or
tins/�apzAaPanv ,Ie y�..J Xv
Certified copy is north, humishm. LENGTH
Certified vis+ilea�dy�the�Ity ins division.
ApP scan,f, 'i, i/i✓Lr..-a FEE SUMMARY
CE RTIFICA E OF EXEMPTION FROM WORKERS'
COMPENSATION NSURANCE
(This section need not be completed if the permit is for one hundred doh n
ears(S1001 or lass.) VALUATION S�o
I cortlfy Nat in the performance of the work for which this permit is
issued, I shall not employ any person in any manner so as to become subject S
to the Workers'Compensation Laws of California.
Dote AppNT: If, T tR/Y//_ s/-Prl/✓1
NOTICEshould
TO APPLICANT: N, hear making this Compensation
p of Exom of the PERMIT FEE `
you sM1 Cold become subject i the Work ars' Compensation nso r This a the
Lebon Code, you must tOr[M1wiN comply with such provisions or this permit
shell be deemed revoked. DATE OF APPLICATION
is coy that I have reed this comply
with al and state that the above noes and
tion c correct. I agree to comply with all city and county above
and
state laws relating to building construction, and hereby authorize represam
tatives Of this city to enter upon the above mentioned property for inspection
purposes.
(wt l agree s. soya, indemnify and keep harmless Na city of ay accrue PERMIT VALIDATIOJV'1
against liabilities, judgments,cons and expenses rmlewhich may i any way attino
aga m/itt d city Inc °uence of the granting of this permit.
I ) Si anu of APPlicant/Convector Data
`
(REQUIRED PRE-INSPECTION IN-PROCESSINSPECTION FINAL INSPECTION
;
INSPECTIONS INSPECTOR DATE h INSPECTOR DATE INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY