R 6448 (2) APPLICATION FOR
CITY OF CUPERTINO NUMBER 8PERMIT 6448
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 PERMIT EXPIRES IF WORK 15 NOT STARTED
WITHIN DAYS OF PERMIT ISSUANCE OR
IBD DAYSS FROM LAST CALLED INSPECTION,
BUILDING ADDRESS
20530-20552 Shady Oak Lane
Cupertino, CA RESIDENTIAL X COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Countrywood Homeowners Assoc.
YES ❑ Ityes s I assembly
req that. ClassA
NAME C/O COillmllnity Management Services root assembly is required.
NO ❑ Initial I.C.B.O.#
ADDRESS 727 University Ave- Los ('stns, (A 95030 EXISTING ROOF COVERING
PHONE 408-395-9606 Attn: Bob Soars NUMBER OF EXISTING COVERINGS 1 (one) each
CONTRACTOR'S
NAME Davey Roofing, Inc. TO BE REMOVED 1 TO BE RETAINED A
ADDRESS TYPE OF ROOF COVERING
CITYazIP 22390 Thunderbird Place, Hayward, CA 945 5 EXISTING
PHONE 510-293-9300 BUILT-UP ROOF
LICENSE
NUMBER 70071D ASPHALT ❑
SHINGLES/pI
LICENSED CONTRACTORS DECLARATION I' te`r-'�.C�
I hereby affirm that I am licensed under provisions of Chapter 9(commencing with Section WOOD SHAKES
7000)of Division 3 of the Business and Professions Code,and my license is in full force and l® _
effect.
License Clava 6'39 Uc,Number
700710 WOOD SHINGLES
Date Contractor nweytoofing, Inc- OTHER(SPECIFY)SSW/
�
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I am exempt from the Contractor's License Law for the following reason.
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,alter,Improve,demolish.or repair any structure,prior to its Issuance,also requires the BUILT-UP ROO
applicant for such permit to flaw a signed r 9(co em that he Is licensed o pursuant to the Provisions D
of the Contractor's Professions
Law(Chapter 9(commencing with Section]000)of Division 3 of the p
Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINS '5JJ
exemption.Any ltyofolt more t5nfive 7031.5 hundred any s($5applicant fore permit subjects the applicant to APR 16
a civil penalty of not more than five hundred dollars with
wag.): WOOD SHAKE ❑
❑I,as owner ofthe property,ar tmy eemployeeswith wages as their sole compensation,will do
work,and the structure Is not Intended does not for sale(Sec.7044,Business and builds
or Cade:thereon,
Contractor's License Law does not apply to an owner of property who builds or WOOD SHING ❑
suchimp thereon,and who does such work himself or through his own employees,improvement provided that Y
such improvements are not Intended or offered for sale.R,however,the en of pr or improvement
Is notSold bull or Improve
for purpose
sale,),ownerbuiltlerwlll have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑h as owner of the property,am exclusively contracting with licensed contractors to construct
the project(Sec.7044,Business and Professions Code:The Contractor's License Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contracts for such projects
with a contractors)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. .5 a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION '
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to self-insure for Workers Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which this / q A /
permit is issued. (/[•�,//� /L• • Seismic
L�I have and will maintain Workers Compensation Insurance,as required by Section 3700 of I
Ihe2all Code,for the performance of the work for which this permit is issued.My Worker's Total v `•
Compensation Insurance carrier and Policy number are:
Carrier fj9ncyNo.t*„QRR17159I PERMIT UTHORIZATION DATE
CERTIFICATE F EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN C.El
(This section need not be completed If the permit Is for one hundred dollars($100)or lass.)
I certify that In the performance of the work for which this permit Is Issued IGhall not employ
any person In any manner so as to become subject to a We is Compensenon Laws of can- All roofs shall be inspected prior to any roofing material b ing
forma. � installed. If a roof is installed without first obtaining an
Date�Appnwam inspection.I agree to remove all new materials for inspection.
NOTICE APPLI NT: If,after making this Cerb kale of Exemption,you should become Applicant understands and will comply with all non clef
subject to the Workers'Compensation provisions of the Labor Code,you must forthwith comply pP P Y P
with such provisions or this permit shall be deemed revoked. source regulations.
I certify that I have read this application and state that the some Information is correctI agree
to comply with all city and county ordinances and state laws relating to building construction,and All roof coverings to be class"C"or better.
hereby authorize representatives of this city to enter upon the above-mentioned property for In- • /G/
spatpurposes.
purposes.
(We)agree to save.expenses
and keep harmless the City ai st Cupertino City-
i against liabilities,
judgments,costs and expenses white may In any way accrue against said Ciry in consequence ATU E OF APPLICANT DAT
of the granting of this 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