R-6447 APPLICATION FOR CITY OF CUPERTINO
NUMBE_ R PERMIT
R- 6447 ,
INSPECTION DIVISION PERMIT EXPI RATION
REROOF PERMIT (408)
(406)777-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11050-11062 Firethorne Drive
RESIDENTIAL X COMMERCIAL OTHER
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS FIRE AREA
YES ❑ If yes—I understand that a Class A
NAME C/o Community Management Services roof assen"is required.
NO ❑ IniEal I.C.B.O.All—
ADDRESS
lADDRESS -727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
PHONE 408-395-9606 Attn: Bob Soars
NUMBER OF EXISTINGCOVERINGS 1 (one) each
CONTRACTOR'S
NAME
Davey Roofing, Inc: TOBEREMOVED 1 TOBERETAINED
ADDRESS TYPE OF ROOF COVERING
CITY aZIP 22390 Thunderbird Pl, Hayward, CA 94545
EXISTINGk(SPECIFY)PHONE 510-293-9300 BUILT-
LICENSE 700710
NUMBER ASPHA ❑
UCENSED CONTRACTORS DECLARATION L hereby eMmn that I am Incensed under prevelons of Chapter g(comvrondn 1 Section WOOD119997000)of DNlalon 3 of the Business end Professore Code,end my Ilc" II In w tlansa. WOODLicenseClew C-AQ Uc.Number 7110 Tt 0
Date Contras«Davey Roofing, Inc. O R
OWNER-BUILDER DECLARATION
I hereby affirm that I em exempt from the Contractors Ucense Lew for the foliowlrig reason.
(Sac.7031.5,Business end Professions Cafe: Any dry or county wTtkM requires a permit to
cc,o,nd,after,improve,tleneffsh,or repair any endure.prior to its Issuance,also requires the BUILT-UP ROOF ]
applicent for such permit to Isle a egnetl statement that he Is Ilwneed punauant to the provlelons
of the Contractors Ucenee,Lew(Chapter B(commenclnpp wnh Section 7000)of DNIslon 3 of Me
Business entl Proleesbns Coes)or that he is exempt Iheretrom and the basis for Me alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.6 by any applicant for a permit subleas the applicant to
e dull penalty of not more than We hundred dollars(5500).1:
C]1,as owner of the property,or my employees with wages as their ode compensation,will do WOOD SHAKES ❑
the work,entl the structure Is net Intended or offered for sale(Sec.7044,Buelness and Proles-
,tons Code: The Ces ontmdors Unruse Lew dose not apply to an mvner of property who builds or, WOOD SHINGLES ElImprovthereon,and"who don such work himself or through his own employees,provided that
such Improvements are not Intended or offered for sale.II,however,Me building or Improvement
Is add within one year of completion,the ownor-bulioer will have the burden of proving that he tlio OTHER(SPECIFY) El build or Improve for purpose of sale.). ,
❑I,w owner of the property,am exclusWly contrectina wnh licensed contractors to constnot
Me project(Sec.7044,Business and Professore Code:The Contractor's Ucense Lew does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who Wide or Improves thereon,and who contracts for such prolecte
with a conmaacr(s)licensee pursuant to the Contractors Unna Law. PROVIDE MFGR.INSTALLATION SPECS.
❑I em exempt under Sac. ,B&P.C.for hale reason
owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION ,
I hereby affirm under penalty of perjury one of the following declaration: yr�
❑1 have and will maintain a Certlf oa,of Consent to aeaansure for Workers Compensation, Building
as provided for by Section 3700 of Me Labor Code,for the performance of Me work for which this
pam'lhA Is l.and $45,542.00 Seismic ��
gI have entl will maintain Workers Compensation Insurance,as required by Section 3700011
the-Labor Code,for Me performerxa of 1.M work for which this permit Is lmad.My Workers
Compeneatlon Insurance carrier and Policy number are; Total ,
canter policy No.California Compensation W985171591 PERMIT AUTHORIZATION . DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION ifthe
INSURANCE 'N.CJ] / /79
(This section need not be completed If 1.M permit Is for one hundred ddlam(51 00)or leas.) /y
I certlty that in the pedorrnarcei of the cod for which this permit Is 1,s ed,i shall not em by
any parson in rner soes to be a ve�eo�p�nmtion Lew,d fan All roofs shall be inspected prior to any roofi g tenial being
torula. / installed. If a roof is installed without first obtaining an
Data Applk:ant inspection,I Agree to remove all new materials for inspection.
Non E APPUCAN 11,she,makin Mie eNllcete of Exemption,you efcukl become Applicant understands and will comply with all non point
subject to the Workers'Compensation ppronnlons of the Labor Cade.you must forthwith comply
with such pro0slprns or this permit shal toe deemed revoked. Source regulations.
I cerdfy that I have read this application and state that the above Information Is correct.I agree
to comply with all dry and county oreinancet and Mete laws rouldrq to buifing corutructen,entl All ro zo ing obe class or better.
hereby authorize representatives of this city to enter upon Me abave,mantioneci property M In- -
epagree
on rpoaea.
(We)agree is save,Indemnity entl keep harmless the Clly al Cupertino Inst IIadM /
oglegran colla and expense,which may Many way accrue epelnet said City In caneequence
of tFhe granting of Mie permit. - SIMArUtIE IDF APPLICANT bAlt
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