R-6441 PERMIT
APPLICATION FOR CITY OF CUPERTINO
NUMBER R- 6.441
INSPECTION DIVISION PERMIT EXPIRATION
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
20587-20607 Cedarbrook Terrace
RESIDENTIAL x COMMERCIAL OTHER
OWNER'S Countrywood Homeowner Assoc. 'HAZARDOUS FIRE AREA
NAME c/o Community Management Services YES �mdysrequired.
NO ❑ Initial LC.B.Oi
ADDRESS 727 University Ave- T:oR Gatnc rA glimn EXISTING ROOF COVERING
r 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
CITY azip 22390 Thunderbird Pl. , Hayward, CA 94545 EXISTING
PHONE 510-293-9300 UILT-UP ROOF ] ,
LICENSE 700710
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provlebns of Chapter 8(commencing with section D SHAKES
7000)of DMsion 3 of the Business and Painfu ons Code,and my license Is In lull forco and
effect. W SH GLES ❑
License Class C39 Lip.Number 700710
Data Corrector nlh,,P.j, nit ..in$��As,_ OTHER ECI ❑
OWNER-BUILDER DEC1ARAfiwN PROPOSED
I hereby affirm that I am m exempt(rare the Contrsctoes License Law for the following reason. PROPOSED
(Sec.7031.5,Business and Professions,Coke: Any city or counry which requires a penult to JUN 0 1r-yJ99
construct,alter,Improve,demolish,or repair any structure,prior to Its Issuance,am requires the BUILT-UP ROO VJ
eppticant for such permh to file a efgmd etatement that he le licensed pursuant to Me provLWons
of Me Contractors License law(Chapter B(ccrnnc ndrg wlth Section 7000)of Christen 3 of the '
.� Business and Profeesbna Code)or that he IS exempt therefrom and the basis for Me alleged ASPHALT SHIN LES ]
exemption.Any violation of Section 7031.5 by any appllcant for a permit subjects the applicant to
e civil penalty of not more then 8ve hundred dollars(5500).): By
01.as awrrer of the property.or my employeae with wage,as their ode compensation.will W WOOD$HAKE
the work,and the Structure Is rot Intended or offered for sale(Sec.7044,Business and Pmfes-
sons Code:The Contmctere License law does not apply to an owner of property who bullas or WOOD SHINGLES ❑
Improves thereon,and who does such work himself or through his own amp"",provided that
such Improvements are not Intended or offered for sale.II,however,the building or Improvement -
issdtlwithincneyearofcompletlon,the owner-bulkterwill he"the burden olproving that hedid OTHER(SPECIFY) Elnot build or Improve for purpose of sale.). -
I,as owner of the properly,em exclusively contracting with licensed cord actona to construct
the proled(Sec.7044,Business and Professioty Code:The Contractors Dcenes Lew does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who bulls or Improves thereon,and who contracts for such projects
with a contrecen(s)licensed pursuant to the Contractors License Lew, PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec. ,B&P.C.for this reason
Owner Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION, PERMIT FEE
' -
I hereby affirm under penalty of perjury one of the following declaration: g(•,2
1 have and wal maintain a Certificate of Convent to seliAnsure for Workers Compe satbn, Bulldln J
as provided for by Section 37W of did Labor Cade for tel performance of the work for which this
perrnb is Issued. $45,542.00 Seismic ' �(U
1L have and wo r maithe tainperformance
resncWorkers f the work Worn Insurance,as requiredsu Section Worker,
0l �b
the Labor Code,for ihe'padormon d of Policy
work for welch this permit is Issued.My Woekeh
Campersetlon Insurance order entl Policy number are: � � Total
Carrier Calfornia Compensation Policy NoW985171591 . PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE NW)O 1 A
(Thio eectbn neetl not be completed II the permit 4 for one huMred ashlers if 100)or less.) 4P
I certify that ip4he performance of the work for h"Iftird7ft Is Issued.I Shell not employ
any personin Yy m r So as to become Sub t rb'-awn sation Iowa of Call. All roofs shall be Inspected prior to any roofing mattenal being
ferule. -�- stalled. If a roof is installed without first obtaining an
. Date 4 Appircam inspection,I agree to remove all new materials for inspection.
NOTI E APPUCANT: If,after main Certn to m
of Exemption,You Should become Subject understands and will comply with all non point
subject to the Workers'Compensation provielort,of the Labor Code,you must breelt,comply
with each provisbna or this."hout i.be deemed revoked, source regulations.
I certify that I have reed tra epplicatlon and state that the above Information is correct.I agree
to comply with all city and county ordinances and state laws relating to bullcng construction,and All roof v gs o be class or better.
hereby authorl representatives of this city to enter upon the above-mentioned property for In.
spection Purposes. \
(We)agree to save,indemdty eel keep harmless Me Gry of Cupertino against Ilablktles, G
judgments,costs and expenses which may in any way accrue against Seat Clry In cenaepuenca SIGNATURE OF APPLICANT D E
d the granting of elle perrnrt.
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