R-6317 PERMIT R_
APPLICATION FOR ., CITY OF CUPERI NUMBER 6 317
REROOF PERMIT INSPECTION DIVISION M cPiRAn N
(408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
to
BUILDINGADDRESS - -
2- ('� RESIDENTIAL COMMERCIAL OTHER
OWNER'S . HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class
NAME "' '} `-"-'� `�— roof assembly is required.
NO ❑ Initial I.C.B.O.M
ADDRESS EXISTING ROOF COVERING
PHONE NUMBER OF EXISTING COVERINGS `
CONTRACTOR'S
NAME \ v�`� TO BE REMOVED==L46TO BE RETAINED
ADDRESS1 r c `y TYPE OF ROOF COVERING
CITY&zIP `S"I' 1�jM s'�4•"21
1 ExlsnriG .
PHONE �t'L�J 7A 3 Q:27 BUILT-UP ROOF ❑
LICENSE ( ' '
NUMBER I —I UO ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION `
I hereby affirm met I em licensed under provlelons of Chapter a(commandng with Section WOOD SHAKES 1X4%
7000)of Division 3 of the Busness and Professions Code,and my Incense Is In lull farce and
effect
WOOD SHINGLES ❑
License Close � LIc.Number� � ��
IqKOTHER(SPECIFY)
bete Oon Il DE /
OWNER-BUILDERacdora DECLARATION PROPOSED
.hereby7031.affirm met l am exempt from Ne Contractors orLicensecoup Lew for the brewing reason.
(Sec.7031 S,alter,lmpr ss antl oloh,or rep Code: Any dry or county wTloh requires a permit to
apnetmnL orstir lmpdemto file eh,«re statement
anystructure,prior liven He issuance,ebo requires provisions BUILT-UP ROOF
of theentforouch permit iceto flaw asigned r 9em meths lehSeced pursuant to Uro pro of
Q
• of the ss and Pre License Lew(Chapter Bisex(commencing therefrom
Section 7000)of for the 3 le fte /
exemption.
and ProbsMans Cede)or that he U exempt antfor mend the basis for the slanted ASPHALT SHINGLES
a dOpan.Airyf net onof Section hundred
tryany applicant brapermd subjects the epplkent to
e dull penalty of net more man five huntlretl tldlare(EBW),I:
C]1,as owner of the Property,or my employees with wagers"her ads compensatlor,will do WOOD SHAKES ❑
the work,and the structure U not Intended oral all for,sab(Sec.7044,Business and Proles-
slonsCode:The Contractors License Law doee:iet appy to` aperty who bualda« WOOD SHINGLES
Improves thereon,and who does such work hlmsill or theuQh le ow byses,provkfed that ❑
such Improvements are net Intended or off for al If,h er, Ing«Improvement
Is said within one year of completion,the o -Ibullder will hese the b of proving that he did OTHER(SPECIFY) ❑
riot Wild or Improve br purpose of web:).
El 1,as owner of the properry,em exckidl'vely cQnir�llrgwlm Nen ntredam to construct
the protect(Sec.7044,Business and Professions Code:Th3Co�i tine o cense Lew does not PROVIDE LC.B.O.REPORT NO.
apply to an owner of property who bulltle or improves thereon,entl he for such projects
with a contractors)licensed pursuant to the Contractors License,L
❑lath exemptunder Sec.' B P.C.for thicrealan PROVIDE MFGR.INSTALLATION SPECS.
OwnerwoRxeasCOMPENSATION DECLARAnoN APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury one of the following declaration:
❑1 hese and will maintain a Certificate of Consent to een-Insure for workers Compensation, Building
as provided for by Section 37M o1 the Labor Code,for the performance of the work for which this ���� -
permiieIssued. Seismic
❑1 have and will maintain Workers Compensation Insurance,as required by Section 37DD of
the Labor Code,for the performance of the work f«which this permit Is Issued.My Workers
Compenaetlon Insurance tamer and Policy number are: huh Total
Carrier PruCOPolicy No. 5�4S0SQDill PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section read net be completed If the permit Is for one hundred dollars($100)or less.)
I earthy that In the performance of the work for which this permit is leeued,I_hell not employ
any person In any,manner so as to became subject to the Warkers'Compenaaten Lawn of call- All roofs shall be inspected prior to any roo?ng material being
formic. - installed. If a root is installed without first obtaining an
Date AyplIcam inspection,I agree to remove all new materials for inspection.
NOTICE TO APPLICANT: If,after making this Certificate of Exemption,you should become Applicant understands and will comply with all non point
subject to Ne Workers'Compensation provisions of the Labor Code,you moat forthwith campy
with such prWisoos or this permit shalCbe deemed ravaksd. Source regulations.
I certify that I have read this appaketbn and Mete that the above Inlor ration Is canna I agree
to comply with etldryand counryordirenceaand state lows relating to bulltlingcanMnnfbn,antl All roof co d class`dor better.
hereby euthodze reprawentativec of this dry to enter upon Ura abovamnntloned property M Ir~
specdon purposes. -f t
(We)agree to ease,Indemnity and keep harmless the Cary of Cupemne,apelnst II all ` . 4
of the gran come and expenses which they In any way accrue against pMd CIry In w GN E D PPLI T DA
of the erantlnp of man permit.
PRE-INSPECTION: PLYWOOD: IN-PROG
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