R-6454 PERMIT R_ 6 4 5 4
APPLICATION.FOR CITY OFCUPERTINO, NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOFPERMIT (408)777.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
20507-20527 Cedarbrook Terrace
RESIDENTIAL X COMMERCIAL OTHER
OWNER'SHAZARDOUS FIRE AREA
Countrywood Homeowner Assoc.
NAMEc/o Community Management Services YES E] ny6s roof assemfrslandirled. ClassA ,
amblyYy b requlren
NO ❑ Irdgel LC.B.O.N
ADDRESS 727 University Ave, , Los Gatos, Ca_ 95030 EXISTING ROOF COVERING
1(One) each
NUMBER OF COVERINGS
PHONE 408-395-9606 Attn: , Bob Soars .
CONTRACTOR'S
NAME Davey Roofing, Inc. TO BE REMOVED 1 TO BE RETAINED
ADDRESS TYPE OF ROOF COVERING
GiTvazlP 22390 Thunderbird Pl. , Hayward, CA 94545, EXISTING
PHONE 510-293-9300 BUILT-UP ROOF [�
NUMBER '700710 - - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm Nat I am licensed under provlalons of Chapter 9(commenclog wlm Sacs WOOD SHAKES Q
7000)of Division 3 of the Business and Professions Code,end my license Is In lullforce an D
e"ecl' WOOD SHINGLES /
License Class C39 700710 Lic.Number D 99
TlAUPY Rnnfing, PECIFY)Tnr- E
De[e CorrectorUC0
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from mor Contractors License Lew for the following reason.
SK.7031.5,Business arta Prolessions Code: Any dry or county which requires a permit to
conebud,alter,Improve,demollsh,or repair any structure,prior to Its Issuance,also requires me BUILT-UP ROOF
applicant for such Will to file a signed statement that he le licensed pursuant to the providons By
of'he
Contractors Dcense Lew(Chapter 9(commencing with Section 7000)of Division 3 of the V
• Business and Professions Code)or that he he exempt therefrom and the baale for the alleged ASPHALT SHINGLES ]
exemption.Any oblation of Section 7031.5 by any applicant bre permit subl.cis the applicant to
e civil penalty of rot more than five hundred dollars($500).):
C]1,as owner of the property,«my emplaymet with wages as their sde compensation,will do WOOD SHAKES ❑
the wok,end the structure Is not Intended or offered f«seta(Sec.70/4,Business and Proles-
Mons Code:TheComrectoreLicarreeLawdoesnetapplytoanownerofpropertywhobuilcis« WOOD SHINGLES
❑
Improvethereon,
s and who does such work himself or through his own employees,provided that
such Improvements we not Intended or offered far sale.It,however,the bulking or Improvement
Is sold within one year W completion,me owmr-0ullder*it have the burden of proving that he did OTHER(SPECIFY) Elrot build or Improve ler purpose of sale.).
❑I,as owner of the property,am exclusively contracfirg with licensed contractors to cmatruct
the project(Sm.70e4,Business and Professions Codo:The Contracture Lkmse Lew doer,not PROVIDE I.C.B.O.REPORT NO.
reply to an owner of property wlc to llds«Improves thereon,and who centred,ler such prolects
with a comrecto,(s)licensed pursuant to me contractor's Dense law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B A P.C.f«this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATt)N DECI-ARATON
I hereby affirm under Penalty of perjury one of the tdlowing dedaratlon:
❑I neve and will maintain.Certnfcete of consent to sen-Insure ler workers Compensation, Building�y .
as provided ler by Section 3700 of the Lab«Code,for the performance of the wank for which this
permt Is leases. $45 542.00 Seismic �
Jr have and will maithe pelrf Woanc e f the work aton
Insurance,m required by d.My 3 W ofWorker's ,
the Labor Code,for the performance of the work r are,which this perms is Issued.My Wokers
Compensenon Insurance center and Polley number era: Tote
Calif., California Compensatiggnay,. W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.0
(This section need not be completed n the permit Is for aro hundred dollars($100)or less.)
I certify that I e performance of the work for which tole permit is issued,I shall not employ
any pare n m ner so as to become sub act to ricers'Compensation Laws of Call- All roofs shall be inspected prior to any r ng material being
forn10 installed. If a roof is installed without first obtaining an
D.le AQpucem inspection,I agree to remove all new materials for inspection..
nsc ET APPLICANT: Il,.her makrg thl certnkate W Exem o�uyonos �became Applicant understands and will comply with all non point
subject o the Woken'Compensetbn provisdn.of the Labor Code,you
with such provisions or this permit shall be deemed invoked. source regulations.
I cerllly that I have read this application and state that me above Information Is correct.)agree
to tangly with all city and county ordinances and state lewa relating to bullding construction,and oof overings to be class or better. O
hereby memorize representatives of this dry to enter upon the above-monibrod property ler int- <
hereby purposes.
(We)agree to esus.Indemnify ami keep harmless the City W Cupertino against Iladlltles,
judgments,coat and expenses which may In anry way accrue against eek City in consequence• �C�NATURE OF APPLICANT AT of the grantln W 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 '