R-6446 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO . NUMBER 6446
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408) 777-3228 - PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN IN DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11063-11113 Firethorne Drive
RESIDENTIAL % COMMERCIAL OTHER
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS
c/o Community Management Services YES p oyes-I understand that a ClassA
NAME roof essernWy is required.
NO O Initial I.C.B.O.M
ADDRESS 727 University_ Ave. , Los Gatos, CA 95030 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 TO BE RETAINED 0
ADDRESS TYPE OF ROOF COVERING
CITY8zIP22390 Thunderbird Pl. , Hayward, CA 94545
T1N
PHONE 510-293-9300 BUILT-UP ROOF
NUMBER 700710 ASPHALT SHINGLES ❑
DCENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provlslonf of Chapter B(commencing with S WOOD$HAKE$.
- 7000)of Division 3 of the Business end Professions Code,and my Ikenea Is In full br ntl
effect.
Ucense Cls, C39 Uc.Number 700710 OD SHINGLES ❑ '
Date Connector Davey Roofing,Inc. (SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
(S /��
I hereby affirm that I em exempt from the Contractors J"nous Law for the foflowirg reason. - D /L1\
Sec.7031.5,Buslrrese end d
Professions Code: Any ry or county which requires a permit to
corakaCi
alter,Improve,denglleh,or repair any stmcture,prior to its Issuance,also requires the BUILT-UP ROOF FM
applicant for such pemtlt to lye a signed statement Met he Is licensed pursuant to the provisions J O
of Me Contractors Udell Lew(Chapter 0(comm eryn�wind Section 7000)01 Division 3 of the. D
,• Buelnew and Proleesbne Code)or that he Is exempt therefrom and No basis Mr the alleged ASPHALT SHINGLES l�il 1999
mption.
exeAny violation of Section 7031.5 by any applkant for a permit subjects the applicant to
e dull penally of net more than INe hundred dollars($500).): WOOD SHAKES
❑I,as owner of the property,or my employees with wages as their safe compensation,will do .By ❑
No work,and the structure is not Intended or offered for safe(Sec.7044,Business and Profes- -
stone Code:The Contractors License Law does ret apply to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided tat
such Improvements are net Intended or offered for safe.If,however,the building or Improvement - -
Issoldwlthlnoneyearofcompletion,the owner-bullder will have the burden of proving that he did OTHER(SPECIFY) ❑
ret WIId or Improve for purpose of sale.).
I,as owner of Me property,am exclusively contracting with Iio msed contractors to construct
Me project(Sec.70",Buslness and Professore Code:The Contractors License taw does net PROVIDE LC.B.O.REPORT NO.
appy to an owner of property who builds or Improves thereon,and who contrams for such projects
-,with a dentranor(e)licensed pursuant to Me Contractors Ucenm law. PROVIDE MFGR. INSTALLATION SPECS.
❑ 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 No blowing drelaretlon: ��•
O1 haw and will maintain a Certificate of Consent to salf4neure for Workers Compensation, Building
of provided for by Section 3700 of the Labor Code,for the perbrmence of the work for whtitl
ich e
permit in leeusd. $45,542.0014!5-0
I$1 have and will maintain Weathers Compensation usurof required by Section 3700 of $el$mIC
to Labor Code,for Me performance of the wcx for which this Parml is Issued.My Workers ✓!--/
Compen
eadon Insurance caroler and Policy number are: Total —1i/0_
Center California CompensatioAlLyNo.W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N,C.I]
ac
(This eilon need ret be completed If its permit Is for one hundred W118 he($100)or less.)
I certify that In Me performance of Me w for whlc hie It b leeueq I shell notemp Toy
faro person I a mann eo ae to become w act a'Compensation Laws of Ceb- All roofs shall be inspected prior to any InDolfirig rutterial doing
installed. If a roof is installed without first obtaining an
Date l/ Appikan inspection,I agree to remove all new materials for inspection.
eu e�a1 o he r�cA monsatircoPrk�sp�ae�ka�f�mYou you shouldbecome Applicant understands and will comply with all non point
You must forthwith cmroy
wind each provisions or this permit shell oe deemed revoked. SOUfCe re stations: -
I deal Met I have read No application and state Not the above Information Is maw.I agree
to comply with all city and county ordlnanms and state taws rotating to Wilding construction,and Alj,fiy3j VIi g$t0 be class Or belief.
hereby authorize a prasenrativee of this city to enter upon No above-mentioned property for In-
spectlon purposes.
(We)agree to few.Indemnity and keep herm oses the City of Cupertino aerial aabilities,
jutlpme ats,meta end expenses which may M any way amrue against mio Gty In casequerlm
• of 1M octan of is parmll. §GNATr5RE OF APPLICANT DATE
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 -