R-0146 PERMIT R_ 0146
APPLICATION FOR CITY EC CUPIVISIC � NUMBER
REROOF PERMIT INSPECTION DIV ISION/�-/� PERMIT E ORKI N
PERMIT 180DAEXPIRES IF WORK IS NOT STARTED
180 DATHIN S F FROM
LASYS OF PERMIT ISSUANCE ON
180 DAYS FROM LAST CALLED INSPECTION.
BUILDINGA RESS BUILDING USE
/ ✓36 C�oL ����/s
RESIDENTIAL f COMMERCIAL OTHER
OWNER'S
HAZARDOUS ROOF III
NAME Laic /�Fit�/SCC- FIRE COVERING
AREA CLASS
ADDRESS 7� i 3rl OL/✓f77�LJ.S EXISTING ROOF COVERING
I
PHONE g7,j NUMBER OF EXISTING COVERINGS
•
CONTRACTOR'S
J� „J S TO BE REMOVED TO BE RETAINED_
NAME /J /� TYPE OF ROOF COVERING
ADDRESS,
CITY&ZIP ,r�Z /��5 I /�, U/rG(J EXISTING
��
PHONE 5�6�'y�'6s BUILT-UP ROOF
LICENSE i/�5�f1(� ASPHALT SHINGLES
NUMBER 7
WOOD SHAKES
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under
provisions of Chapter 9 (comm
en-
eine'Wim Sa'titn 7000) f Division 3 of me Business d P, (.salons Code, WOOD SHINGLES
and m5 n Is in f)i,� tat. //. .G
License Cl Lo nae oaf OTHER (SPECIFY)
OWNER BUILDER DECLARATION
I hereby affirm that I am exempt from the Contractor's License Law for PROPOSED
,he following reason. (Sec. 9031.5, Business and Professions Code: Any city
.runty which requires a permit to construct, alter, improve, demOhsM1,of
repair any 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 int Contractor's License Law (Chapter 9 (commencing wlm Section 7000)
of Division 3 of the Business and Professions Cutlet or that he is exempt there
ASPHALT SHINGLES
from and•the'basls for he anaged expon. Any violation of Section
.r.. 7031.5 by cry applicant for a permit emti
subjects the applicant to a civil penalty
of not more tat five hundred dollars($500).1: WOOD SHAKES
01. as o .of_mw (
e.p, erty. n my employees with wages as their sole
compo osatlon will do the work, and the structure is not intended o offered
for sale (Sec. 704., 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
such imp .vameets are not intended o offered for sale. If, however, the OTHER (SPECIFY)
building or ireprovere do, is sem within one year of completion, the owner
builder will have the burden of proving that he did not build or improve for
purpose of sown PROVIDE I.C.B.O. REPORT NO.
❑ I, s Owner st [M1e property, a exclusively contracting an with Reamed
code' tors to construct the project (Sec. 7044, Business and (property
Collo: The or improves thernseeon,
Lawand doesowho contpplyracts
'.anSuch
of with
a PROVIDE MFGR. INSTALLATION SPECS.
Who builds o eased pursuant
meant n, and who contracts fore La peiojec[s with a
infract am licensed pursuant to the Contractor's License Low.
❑ am exempt rndn. San. ,B.aP.c.for thisreason - FASTENER
Owri Date
WORKERS'COMPENSATION DECLARATION
I hereby affirm that I have a certificate of consent m self.insure,Ora TYPE
tlficate of Workers'Compensation Insurance,or acertified copy thereof(Sec. +
3800, Lab.�/li•,,
PalicV No. Cool
�I tl4led coot is M1er by furnished. LENGTH
Cerfitled cop flits -m my city inspection division.
Apsilicont nn �/..-.t,1,E FEE SUMMARY
_ CERTIFICATE OF EXEMPT10& FROM WORKERS' r
COMPENSATION INSURANCE
(This section need not be completed if the permit is for one hundred dol
s(deep) .)
I... e troy thatthat in the performance of the work for which thiVALUATION
s permit is
issued, I shall not employ any person in any manner so as to become subject
to the Workeri Compensation Laws of California.
Date Applicant
NOTICE TO APPLICANT: It, atter 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
shall be deemed revoked, DATE OF APPLICATION
I certify that I have road this application and state that the above informs
tion is correct. I agree to comply with all city and county ordinances and r IT
stat. laws relating to building construction, and hereby authorize represen- }
taliVes Of this city t0 enter upon the above mentioned property for inspection
purposes.
(We)'agree to save, indemnify and keep harmless the City of Coperrno PERMIT VALIDATION
against liabilities,judgments,costs and expenses which may in any way Secret
ig said City on equence of he granting of this pe t.
at l�n�scPf ,�u� °7/S
Bnalufe oZApplicant/Cont actor Data
REQUIRED 'PRE-INSPECTION IN-PROCESS INSPECTION FINAL INSPECTION
INSPECTIONS INSPECTOR DATE_ INSPECTOR DATE_ INSPECTOR DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
INSPECTOR COPY