R-6445 PERMrr
APPLICATION FOR clrY of cuPEHTINo
NUMBER R . 6445
INSPECTION DIVISION PERMIT EXPIRATION
'REROOF PERMIT (408)777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
• 160 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
20557-20579 Cedarbrook Terrace
RESIDENTIAL % COMMERCIAL OTHER
OWNER'S HAZARDOUS FIRE AREA
Countrywoodmmuni Homeowner Assoc. YES ❑ Ifyes—IundersmndmataClassA
NAME c/o Community Management Services mot assemhty is required.
NO ❑ InWal I.C.B.O.M
ADDRESS 727 University Ave- , Los Gnrns, CA 930'ln 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 1b BE RETAINED
ADDRESS TYPE OF ROOF COVERING
CITYazIP22390 Thunderbird PI. , Hayward., CA 94545 EXISTING
PHONE510-293-9400 BUILT-UP ROOFLICENSE
�C]
NUMBER 700710
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECORATION
hereby affirm titat'I am licensed under provisions of Chapter B(commencing with Section OOD SHAKES �C]
7000)of Division 3 of the Busreas and Professors Cobs,and my license Is In full force and
effect. HINGLES ❑
License Cas C39 Uc.Number 700710
Dale contract« Davey Roofing, Ins OTHE CIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that 1 em exempt from the Canlractors Ucense Law for the following reason. -/�
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,after,improve,demolish,or repair any structure,prior to ice Issuance,also requires the BUILT-UP ROOF D
eppl=t for such permit to Ne a signed statement that he Ie Ikened pursuant to the prowalons
of Me Contractors Ucerao Lew(Chapnr B(commencing with Section 7(00)of Division 3 of the• J U N Business entl Profession$Code)or thmat he Is exempt therefroand the basis for the alleged ASPHALT SHINGL 1999
exemption.Any vlotation of Section 7031.5 by any applicant for a permit su fects the applicant to
a civil penalty of not more than five hundred dollen
❑I,as owner of the property,or my employees with wages as their ache compensation,will dWOOD SHAKES
'❑
the work, W the structure Is not Intended on ofleretl e(S
for salec.704x.Business and Protons-
ekes Cod::The Commicmre Licerma Law aces not appy to an owner of property who B RI w WOOD SHINGLES y
Improves thereon,and who does such work hlmsell or through his own empic,",provided!that
Such Improvement are=Intended or offered IN sale.If,however,Me building or Improvement
is sold within one year of comp'atbn,the owner-builder will have Me burden of proving Mat he did OTHER(SPECIFY) El.
rot bulk)or Improve lcr puryo$e of$are.).
01,as owner of Me property,em"cluslvely contnchmp with licensed contrectars to construct
iia de:The project(Sea 7044,Business end Professions CoContactors Ixerue 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 projects
with a coniractods)licensed pursuant to the Contractors License Law. PROVIDE MFGR.INSTALLATION SPECS.
-11 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
YORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the folkmtrq declau lora: '
❑I have and will melanin a Certificate of Consent to sell-insure for Workers Compensation, Building
as provitled for by Section 3700 of the Labor Code,for the performance of the work for which Mie M
Permit hawed. $45 542.00 Seismic marc.) V
gi have entl will maithe palrt Workers f the wuwtlon Insurance,hickthis as permit
by Section 3 1X)ofWorker's
s
the Labor Code,for the parfonnance of the work for which ilia permit le Issued.My Workers
Compensation Insurance carrier etN Policy twmber en: - Tota
Carrier California Compensati9�614p W985171591
PERMIT AUTHORIZATION DATE .
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.CQ / 1
(This section need not be completed If the permit Is for one hundred dollars($1 DO)or les.) - 6
I cedlfy that In the performance of the work for which INS It Is Issued,I shall not empty
any person 1n am ma nor so as to became aubject a mpensetbn Lewy el Call- All roofs shall be inspected prior to any roofing matenal being
efnla installed'. It a'roof is installed without first obtaining an
Data 9 applkart "� inspection,I agree to remove all new materials for inspection.
NOTI ETOAPPLICANT: It,after making Mie Coufficate of Exemption,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensallon provisions of Me Labor Cade,you must forthwith comply pp p y p
-with Such provisions w this permit"Ift be deemed revoked. source regulations.
I oertity that I have read this application and state that the strove Information Is correct I agree
to comply with all city and counly ordinances and state laws relating to building construction,end . All roof Wv$kgs to be ClasS�Or better. -
hereby nulhorlxe representatives of We city to Baler upon the above menibned property for M, / /�
Spector purpose S, ',[-/(`/ /
(Wel agree to save, density and koep harmless the City of Cupertino epelrol IlebNtles,
Judi manida,coat uma tin wpe`see whkn may In any way aarw against sold Gty n consequence SIGNATURE OF APPLICANT ATE
p p pernit.
PRE-INSPECTION: PLYWOOD: - IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL: '
INSR _ DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
0FFICE COPY