R-0190{ y . D
u4r ." ' t• r t-•..k,'mn..e�,`l'' yi �' zi`y '".7.i, :.r«ti t� �,. y +' '' '. PERMIT `. 4
`r "_ - ...icAP-PLICATIOWFOR '�'r`a_-'r' �- CITY 01`etUPE'RTINOF -NUMBER`R`"-01 90,
REROOF PERMIT INSPECTIONS DIVISION PERMIT EXPIRATION '
CC •^s, PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
�4r 180 DAYS FROM LAST CALLED INSPECTION.' BUILDING ADDRESS - 'Its, .+f s"'`Yrtz� .-n t,• -r,�:1y BUILDING USE '`•
DJ a7' ,zx(/ijlc�/ 'RE,
SIDENTIAL .COMMERCIAL - C^'' 0 T ER
1, OWNER'S;,"
s ! 8 .
NAME HAZARDOUS y' -' ROOF
FI
RE COVERING +
Qq I' AREA CLASS
�{ F ADDRESS /r/•��� �iQLD sTiq : - EXISTING ROOF COVERING
A'• vaw���n'•'rrr'is+#Adbw`'`o 4: :its. "r' �. r .;.. - T
y ,',' y:a •7. NUMBER OF EXISTING COVERINGS
...Hw .PHONE 7(3a- ,; Oy G; 1-r 51
CONTRACTOR'S.
a .P;- 7.�6 X � f �/C�5 TO BE REMOVED TO BE RETAINED
NAME ��-'' /' C—O TYPE OF ROOF COVERING
a `ADDRESS;
CITY&Zip L ` 7-J �,� EXISTING
O .l
XL
9vav -
BUILT-UP ROOF -
PHONE 5 ^
LICENSEi""'' q ASPHALT SHINGLES
4 sr NUMBER
e._. a. WOOD SHAKES
3`4 LICENSED CONTRA TORS DECLARATION —�
• i IT byyaff fi th he,I arpltcamiidodrbup s 1 C'apta 9( ommen
y sy m g,w th S co j700 o D,, u°ny'"t. of l :,S s /�z p Pro+ Cc do, WOOD SHINGLES
mil e1{f pc
-ycom�aP[.or i OTHER-(SPECIFYP/
�'..''.. r ..
Th BUILDER DECL`A RATION
j
t wn OaM1 bV affirm
emal 1 IM1 C t License Law for
he+0110 B son Ise 7031
, e sbas tl P f Code Any ty
PROPOSED
cot;my which 5 p031!5 In O St t I., improve ch.nniflish,cir
Png Ianystructure,po sra0Isoqs pPII [+O
) IO 1 Signed BUILT UP ROOF
'B ed tet t.th t M1 b4 5 d P t n
o: lh 'Court.. to 4 LiF.msd Law ICM1 ptei (co n B 'thy Ion 7000)
oD; o t3 fthe B nese and P of ss O C°de)
a M1 i.
+a''t�^'•' oo,that exempt therey. .
• tz.
.Y
`ASPHALT SINGLES:•from d m boa for the Regard Section
70 5 any fant for a pm I bryct In applicantto e Civil Penalty
ofnot fura mefive hundred ($500))V� ❑ I, s.ownar of Ino properly, o} y' mployees wrwagWOOD SHAKES
Fas.;Their ?
- .•,
fomp ansa tion,will do the work, and Th.shut Sure isnot intended Or Offered ' p:
r saw( Sec. 7044, Business and Professions Code: rhe cor 'WOOD License WOOD SHINGLES
+ Law does not apply t°an Owner of property who builds°r improves[hereon,
and Who Coos such work himself Or Through his own employees,Provided that j
IT such improvements are no, intended Or offeredfor sale. If, however, Ino OTHER'(SPECIFY) -
s building or improvement is sold within one Yuri;of bomphitium, mn
In.o
y. builder will have he burden of proving mat he Bid-not build or improve for
•,"%";�,,. .., °prpo4aylJspf. 1R^,�VIDE C B.O. REPORT N0.
3 OW oM1 p P [Y 1 Y40 a��' g mill p4¢tl^�+T}^' mow.+��-„
nirto io o st ct th p j 11S 7044 ryB sl s ntl Polo sions
11 cod¢ me cot m L' L d or IipW ro P e of Property ' :y.P.ROVI.DE.MFGR. INSTALLATION SPECS.
h0 b Ids O p O Ih and h° tim a Cn'Pr O1ec15 with a �a
comractor(s)licensed pursuant m the Contractors License Law,
❑ 1 em exempt under S.F. ,B.&P C.for his
ta4on FASTENER
O ne � � Date
WORKERS'COMPENSATION DECLARATION / Al that I nava i certificate t f consent i eco'neurer o a ser .TYPE U/�_ �LJ�II/(
t lice[ OI Workers'
ry��•pCo`�mpensefon insurance,or certified copy�Thlera0lO(S)ec� �j •
+ 3800y Lgd;l •S.�Q.-n �Q�urplar, J T J !i r'F r` "�. ., a . -/�_ ry,/ /J/,/.` .J _T _ ...
Certified copy hereby fur n d LENGTH l"i r iC7GX• e 1� �{
. ASpI. cPIS n I t/ +'Iod ym. 'ty/ pRtli agdr�jaion. 17
TE O/ cE PTI/ON F M RKERWO s' FEE SUMMARY
COMPENSATION INSURANCE
(This section need OI b completed I thepermit 51 hundred d I _ G /
{1.+r-� s(stool less.) ri$' - - �z ti.'VALUATION �IJ !O .
Y 1 l: t 1X tih t in tM1 Pe fo a o o+ Th o k f wM1 h m p t _ _ •r'
I Lied 1 Snell¢ of
employ any p r y 5 t Eucope.sm,'..,-'r''
4 to Th
Wo ka s Com Pe seYo 'L-urs i C +o leP h "'a-WA� i11yv"'I " Q• k 5. J
Date Applicant
NOTICE TO APPLICANT If, after beliking,mis'Corlifit.h. + E_ pt 'PERMIT FEE
f you should became s bl t to the Workers.0 mp .s [ n pro O
M1 I the ,
LaborCode, y u List f.,Ih-m comply with'sucP
bi rov s ons cr [ s permit '
shall be apo d evoked. " DATE OF A PLI A ONI <
I ca,tify that I have road this application and St.,.Th., be above informs
tion c, I agree to Comply with all city nd'county ora nadF.S and __ /�
state I s al t ng IO building Itl ng const Lt On and hereby author z represen te //
tatives Of ahlS`FIT 1.enter upon th aba a-mesont ¢d property for l/_or impactscm
waryy e t ea v nd5kaep harmle the City of Cuper[no r PERMIT VALIDATION
J ego st1'ab Iles Purp 1.
jutl [ osis qqnnd ape of wM1 n .V 'a y w y accrue . n' r r z ✓ '
ti - a mot C y in c s ifh a t f to
A�J Signa[ re of APPlic i/Contractor - l DetO J �' i
. REQUIRED PRE-INSPECTION - IN-PROCESS INSPECTION / FINAL INSPECTION
INSPECTOR r. ' DATE INSPECTOR. 4 DATE � INSPECTOR _ DATE_
'NOTE--- OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FORTINSPECTION
INSPECTOR COPY