R-6450 PERMIT R_ 6450
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228.. PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1B0 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
• BUILDING ADDRESS
11030-11042 Firethorne Drive
RESIDENTIAL_x—COMMERCIAL OTHER
OWNER$Countrywood Homeowners Assoc.. HAZARDOUS FIRE AREA
YES ❑ If yes-I understand that a Class A
NAME c/o Community Management Servicesroof assembly is required.
NO C] Initall I.C.B.O.a
ADDRESS 727 -University Ave. - Los Gatos CA 95010 EXISTING ROOF COVERING
PHONE 'S NUMBER OF EXISTING COVERINGS 1 each
CONTRAC
Davey Roofing InC.• TO BE REMOVED 1 TO BE RETAINED
NAME - . ,
ADDRESS TYPE OF ROOF COVERING
CITYaZIP22390 Thunderbird Pl. , Hayward, CA 94545
EXISTING
PHONE 510-293-9300 - BUILT-UP ROOF $]
NUMBER ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby efftrm Met I am Ilcensetl under provision of Chapter 9(commencing with Se on WOOD SHAKES g]
]000)of DNlsion 3 of the Budtsss end Profession Code,and my license Is In full force
affect. C39700710 WOOD SHINGLES El
Ucense Cleo! Lb.Number
Date Cismeacter Davey Roofing, Inc, OTHER (SPECIFY)
OWNER-BUILDER DECLARATION
e lolbwinp reason. PROPOSED
hereby affirm that I em exempt from the Contractors License Lew for in
D ILI
(Sec.7031.5,Business and!Professions Code: Any city or county which requires a permit to n 1
corsbud,eller,Improve,demollsh,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement that he Is Ilcensod pumuent to the prminlons O ����
of the Contractor00)s Ucense Law(Chapter 9(commencing with Section 70of Division 3 of the
Business and Profensbrts Code)or that he is exempt therefrom and the basis for the alleged ASPHALT SHINGLES 11
axempdon.Any vloktlon of Sai 7031.5 by any applicant ler a Permit wbjecte the applicant to
e cw penelty,d not more than IM hundred dollen($501 B
01,as ono of the property,or my employees with wages as their ado compensation,will do WOOD SHAKES y ❑
the work,and the structure Is rot Intended or offered for sale(Sec.7044,Business and Prof rs-
. dons Code:The Coneectors License Law does not appy to an owmer of property who bulbs or WOOD SHINGLES ❑ -
Improvee thereon,and who tloes such war,himself o through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the bulldlig or Improvement
Is sob within one year of completion,the owner-0ullder will have the burden of proving that Ina did OTHER(SPECIFY) ❑
W build or Improve for purpose of sale.).
❑I,as owner of the property,em exclusively contracting with licensed contractors to corstrud
tite project(Sao.70",Business and Professions Code:The Contractors License Lew does nd 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 contrenor(s)Wensed pursuant to Me Contractors Ucense Law, PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for his reason
owner - oats
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury"one of the fdlowing declension. - ,iy�
❑I have and will maintain a Certificate of Consent to sell-Insure for Workers Compersatlon, Building ,r.s
u
provided for by Section 3700 of the Labor Code,for the perlormenc,of the work for which his $45,542.00
permit is leeuetl. Seismic
,[]I have and will mountain Workers Compensation Insurance,as required by Section 3]00 of '
M Code,for the performance of the work for which title permit Is Issued.My Workers• �F/
compensation Insurance terrier and Policy number are: Total L�
Cants California ComnensatigeneyNo. W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE' N.CQ
(This section need not be completed it the permit Is for one hundred dollars($100)or less.)
Iced at In Na perbrrrence of Ma work for wh Nle p nnit le Issued,I shall not employ 1
arty Pon a m nor w as to become e n t a mzam�panaatmn Laws of can. All roofs shall be inspected prior to any roo p material being
forms. '` / installed. If a roof is installed without first obtaining an
net. 1� "Isent inspection,I agree to remove all new materials for inspection.
NOTICE TO APPUCANT: If,after maklrg thlaiCeellficate,of Esempibn,you should becortn applicant understands and will comply with all non point
subject to the Workers'Compors rfon provisions of the Labor Code,you must fothwith comply
with such provisions or this pemdt shell be deemed revokedl source regulations.
I cerlHy that I have read MIs application and nate Met Ihe some Information Is correct.I agree
to comply with all city and county ordinances and state laws relating to building construction,and - AV001v nits to be Class° or better.
hereby aspectbon uthoress a repreeentatNea of this city to enter spm the above mantlonetl property for In.
(We)agree to save,Indemnify and keep harmless ttn City of Cupertinoage Inst liabilities,
Judggmenb,poem and e�enses whch may In any way accrue against sald City In consequence 3 G TU OF APPLICANT T
the granting of MIs permit.
PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP. DATE INSP. DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INS& DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY