R-5900 APPLICATION FOR clTv of cuPERTwo
NUMBIERR- 5900
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
' WITHIN 180 DAYS OF PERMIT ISSUANCE OR
t
BUILDING ADDRESS
180 DAYS FROM LAST CALLED INSPECTION.
� � Buss
RESIDENTIAL COMMERCIAL OTHER
OWNER'S / //� HAZARDOUS FIRE AREA
YES ❑ If yes—I Imck rstend that a Class A
NAME— roof assenbly is required.
NO ❑ Inifia I.C.B.O.k
ADDRESS v EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS
CONTRACTOR'S
NAME �'M�� 1 TO BE REMOVED �` TO BE RETAINED
I/,//� Q
ADDRESS
ZIP 1�.7�! U�l��✓ �� TYPE OF ROOF COVERING
crrY EXISTING
PHONE BUILT-UP ROOF
LICENSE 2
NUMBER / ASPHALT SHINGLES ) /
UGENSEDCONTRACTORSDECUMTION 6
1 hereby amrtn Met I am Ikonmtl uMar provlSlons of Chapter a(commencing with Secllon WOOD SHAKES
7000)of DNblon 3 of the Guar ees and Professions Code,end my license is M We torte and
effec` 71? WOOD SHINGLES `]
Ummas Class c.Number l � �/
Data z contractorA 4, oYt l OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED .
I hereby affirm that I am exempt from me Contractors License Law for Me folabng reason.
(Sac.7031.5,Business end Professions Corte: Any dry or county which requires a permml to
m sit=,after,Improve,demolish,or repair any structure,prior to its issuance,also requires the BUILT-UP ROOF ❑
applicant for such permit to his a signed statement that he Is Ibensed pursuant to the provisions
' of the ss an dor,Ucanas Lew(Chapter 8 Is ex(commencing with om and 7000)of for ionthe 3 le ed
ex
Business entl Professions Code)or that he b exempt therefrom and Ma beefs for Me applicant
to ASPHALT SHINGLES
exemption."n.Anyf not more
of h aclbn hundred
by any applicant for a permit aublade the applicant tc
e dull.amity of not mora Men five y employees
dc4layees (S500).):
wcx*, ownerplMeproparry«nryded or eeewith r mate ulelrmb mmpew,"Pritido WOOD SHAKES
me work,entl Ie structure Is not Intemm,Lmv ores not for sub m owner of Property
end uilds o-
ebreCotle:The Contredorees snse Lewtlimself apply to rthmghhisow r olproperty wiwidool that
WOOD SHINGLES n �I
or
IrtprWss thereon,and who ones such workred fort or ,If,how his own emilding or improved Met q A � fi
such impmemenbere not platin,tended the
owtnatlfor,abwf,haveveq maenof pr or gthavement t he did
tom uildorwithin
provyear for purposelof stheownenEulltlerwlll hew the burden of proving thathetib OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.):. 1 ''I
L]1,as owner of me property,am exclusively contrectlrp with licensed contractors to construct a1111�2,� AINNf
me project(Sec.7044,Business entl Professlors Code:The Contractors License Lex doe,not - PROVIDE I.C.B.O. R f TV AN r1
aPI to an owner of property who billd8 or Improves thereon,and wM contracts for such projects
with a conlradorts)licensed pursuant to Me Comrectors Uicenm Law. PROVIDE MFG R.`INSTALLATION.SPvCS.
O 1 em exempt under Sec. ,B 5 P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm antler penalty of perjury one of the f xio ring dedaratbn: 12-7
❑I have and will maintain a Certificate of Consent to self-Insure for Workers Compensetbn, Bulldlin
as provided for by Section 3700 of the Labor Corte,fon the performance of the work for which this g
permit Is Issued. 7 Seismic o d
❑1 have and will maintain Workers Compensetlon Insurance,as required by Section 3700 of
the labor Corte,for me Performance of Me work fon which this permit Is issued.My Worxere TORI 217 LO Ireurence unler on Ik:y number are: -
Carrier 'Policy No. 3y 0 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ
(This section nmtl not be cornplated If the permit is for one hundred dollars($100)or bee.)
1 certlty mat In the performance of tire work for which this permit Is Issued,I shell not ampby
arry,person In arty manner m as to become subject to Me Workers'Compensation Lowe of CCeellI- All roofs shall be Inspected prior to any roofing material being
fom'a installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: It,after making this Certificate of Exemption,you should become Applicant understands nd will tom with all non pint
Subject to Me Workers'Compensation provisions of the Labor Code,you must forthwith comply PP pis P
will,a Provisions or Ila permit abet be deemed revoked. source regulations.
I certify that I have read IU application and stele that the above Information Is coned.I agree
to comply wit of dry end county ordinances and state laws relating to bulking ccrwwctbn,mcl All roof C e lass or better. '
hereby authorize representatives of this city to enter upon the above-mentlone I property for In.
spectlon purposes.
(We)agree to anus,Indemnity and keep harmless the City of Cupartlno agabet liebllllbs,
' of thmenb,corm and expenses which may In any way emus against eek Ci
ry In caruequence NAT F APPLICANT DATE
W Me Nco of Mb permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
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