R-6455 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R 6 4 5 5,,
INSPECTION DIVISION PERMIT EXPIRAn N
REROOF PERMIT . (408) 777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
20537-20549 Cedarbrook Terrace
RESIDENTIAL x COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA'
Countrywood Homeowners' Assoc.
VES ❑ If yes—I ln"Is req tired. Class A
NAME c/o GotlLunit:y Management Services roof aRsernbly is rerpilred:
• NO ❑ Irldtal LC.B.O.Y
ADDRESS 727 University •Ave. , Los .Gatos, CA 95030 .EXISTINGROOF COVERING
PHONE 408-395-9606 Attn: Bob Soars NUMBER OF EXISTING COVERINGS I(One) each
CONTRACTOR'S
TO BE REMOVEDI - TO BE RETAINED
NAME Davey Roofing, Inc.
ADDRESS 22390 Thunderbird PI. , Hayward, Ca 94545 TYPE OF ROOF COVERING '
CITY a ZIP
EXISTING
RHONE 510—.293-9300 BUILT-UP ROOF g] 0 D
LICENSE n
NUMBER 700710 ASPHALT SHINGLES 99
- LiCENSED CONTRACTORS DECLARATION q
I hereby affirm that I am licensed under provlslons of Chapter a(ecmnnendng with Section WOOD SHAKES
70(0)of Drdslon 3 of the Business anal Professions Code,and my 8cense Is In lull force and
effect. \
WOOD SHINGLES
uceme Cleo C39 Lk;.Number 700710 ❑
Date contractor Davey Roofing, Inc.. (SPECIFY) \;❑ %/
OWNER-BUILDER DECLARATION icy
'I hereby affirm that I am exempt from the Contractors License Law for the following reason. /
(Sec.7031.5,Business and Profeesio m Code: Any city or county which requires a permit to
construct,alter, demollsh,or repair wry structure,pilon to its Issuance,also requires the BUILT-UP OOF fr]
applicant for such printed to file a signed statement that he Is licensed Pumtent to the pravisione
of the Contractors Ucane r Law(Chapter B(carrunencirq with Section 7000)of Division 3 of the -
• Business and Proleeelons Code)or that he Ie axempl lheretrom and the be"IN the alleged ASPHALT SHINGLES
"Implicit.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
e civil penalty of W more than five hundred cidlere($500).):
❑I,as,owner of the property,«my empkyeas with wages as their sole compensation,will do WOOD SHAKES El
the work,erre the structure Is not Intended or offered for sob(Sec.7044,Business and Proles.
along Code.The Contractors Uconm Law does not apply to an owner of property who bullet or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own emplDwes,provldod that ❑
such Improvements are not Intended or offered for sale.II,however,the building or Improvement
Is sold within one year of completion,Me owner-bulkier will have the burden of proving that he dM OTHER(SPECIFY) El
build or Improve for purpose of sale.).
❑I,m owner of the property,am exclusively contracting with licensed contractors to ocestruct
the project(Sec.7044,Business and Professions Code:The Contractors License Lew 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 project
with a comhactor(s)Ibaneed pursuant to the Contaunces LIcenes Law.
❑I am exempt under Sec. B a R C.f«tits reason PROVIDE MFGR.INSTALLATION SPECS.
Owner Data
WORKER'S COMPENSATION DECIARAnON APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally of perjury one of the following dedaratlon: �)
❑I have and wlli maintain a Certificate of Consent to wit4nsure for Workers Compensation, - Building L
m prwlded for by Section 3700 of the Labor Code,for I performance of the work for which this $45 542 00
pennit is Issued. Seismic
X'-71 he"and wu maintain Worker's Companaatlon Insurance,as required by Section 3700 of
Jiro
bar Code,for the performance of Ne work for which this permit Is leaned.My Worke's SG•Jct
Compensation Insurance carrier end Policy number we: Total
Carrier California .nmp nsa OgicyNo. W9851 71 591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 'N.C[7
(This section need not be completed If the pemdt Is for one hundred tldlam($100)or lase.)
I county that In the performance of the work for which ills permit Is Issued,.I shall not em oy
any pare m annor s,as to become wbj tat' gi$eq`n Lawn of ail. All roofs shall be inspected prior to any r ofi m Tial being
f°`mla. installed. If a roof is installed without first obtaining an
Dat,,Y applkan, inspection,I agree to remove all new materials for inspection.
f40 O APPUCANT: If,after making thl Cer ficat d Exemption,you should become ,applicant understands and will comply with all non point
wbl to a W'«kers'Compenst provisions of the Labor Code,you must forthwith comply
with such provisions or this permit shelCbe deemed revoked. source regulations.
I certiy that I have read this application and state that the above Information is correct.I agree
to corrpy,with all city and county ordnance,and state leve ratting to bulltling a7rretructlon,end AllWce ' sto be class or better.
hereby authorize representatives of Nis city to enter upon the abw rrk ntionod property for In.
\ 9
.fraction(W ) aureate,. `/
(Wer)agree to serve, Indemnify and keep hennlem the City of CupeNrno against IIebIlNlee, /
Judgments,cost erre expenses which may In any way.accrue against said City In ronsequenca
of the granting of this permit. SI N TU OF APPLICANT D E
• 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY