R-6442 PERMIT R_ •6442
APPLICATION FOR CITY of CUP eRTINO NUMBER
INSPECTION DIVISION. - PERMIT EXPIRATION
REROOF PERMIT _ - (40$)777-322$ ,PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
. BUILDING ADDRESS -
14057-11069' Plowering Pear Dr.
Cupertino, CA RESIDENTIAL X COMMERCIAL OTHER
OWNER'S - - HAZARDOUS FIRE AREA .
Countrywood Homeowner Assoc. . YES.0 If yes—I unadmitand Thom ClassA
NAME c/o CommunityManagement .Serdices' nofasselisrequired. ",
NO L] ,Initlal ICAO.R
ADDRESS 727 -.University Ave. , lios Gatos, CA 95030 EXISTING ROOF COVERING .
PHONE 408-395-9606t NUMBER OF EXISTING COVERINGS
-1 (one) each
CONTRACTOR'S -
NAME Davey Roofing, Inc; TO BE REMOVED 1 TO BE RETAINED '
ADDRESSTYPE OF ROOF COVERING
CITY aZIP 22390 Thunderbird P1. , Hayward, CA 94545
EXISTING
PHONE 510=293-9300 BUILT-UP'ROOF' [ .
LICENSE
NUMBER - 700710 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION.
I hereby affirm that am licensed under provlelons of Chapter B(commencing WOOD SHAKES
7000)of Dlvielon 3 of the Business and Professions Cade,and my license is In full force
effect. -
DSHINGLES D '
Ucense Clens. C49 Lk.Number 7(1071 D
Davey Roofine, Inc. THER (SPECIFY) AP1 s
Date Contractor 1999
OWNER-BUILDER DECLARATION PROPOSED f•.
hereby ,Bu that em exempt from the Code: Anytcity License Law for the uiresfollowing reason.
(Sec.7031.5,r,imp oee antl Prosh,or re itanAny city m county which re,also a air s t to -
conetrucL alter,Improve;to file demolish, statement
any e,mor to he issuance,to ma requires the BUILT-UP ROOF n
applicant for permit to file a signed Matement that he le Ilceruaei pursuant to prwlelone By
. of the Contractors License Lew(Chapter B(commencing with Section 7000)of Division 3 of the
Business and Professions Code)or that he Is"awl therefrom and the basis for the alleged ASPHALT SHINGLES
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the appllcant to
e civil penalty of not more than five hundred dollars(1,500).p
L]1,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
the work,and the structure U cwt Intended or offered for sale(Sec.7044,Business and Profes-
sions Cade:The ConlragaYe License Lew does not apply to an owner of property who bullde or WOOD SHINGLES -
Improve�thereon,and who does such work himself or tr ough his own employees,provided that ❑
such Improvements are not Interam or offeretl for safe.If,however,the building or Improvement
Is sold within one year of completion,the owner-bulkier will have the burden of proving that he did OTHER(SPECIFY) ❑
not build or Improve for Purpose of sale.). ,
❑I,as owner of the property,am exclusively contrecting with licensed contractors to construct
the project(Sec.7044,Business ani Profeaelcne Code:The Contractors Ucenae Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who builds or Improves thereon,and who contreas for such projects
with a contractors)Ilcensetl pursuant to the Contractors Uoedee Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ',B&P.C.for this reason .
Owner - Date APPLICATION DATE VALUATION PERMIT FEE
- WORKER'S COMPENSATION DECLAFiAT10N '
I hereby affirm under penalty of perjury one of the following declaration:
❑I have and will maintain a Certificate of Consent to seM4nsure for Worker's Compensation, Building
as provided for by Section 3700 of the Labor Code,for the performance of the work for which file c
permit Is Issued. ,mjelSnllC
�{�]] have and will maintain Workers C.Ireneatien Insurance,as required by Sectlon 3700 of /
th6Lebor Code,for the performance of the work for which this penult is Issued.My Worker's
Compensation Insurance canter and Pdlry number are: Total
Carrier California Cnmzannatil&UCyN0. W98517IS91 PERMIT AUTHORIZATION DATE
-CERTIFICATE OF EXEMPTION FROM WORKERS' - -
COMPENSATION INSURANCE N.C.L]
(This samon need not be competed 1 the Permit Is for one hundred coils
re(5100)or less.)
I cerUtythat In the performance of the work for which this permit Is Issued,I shell not.=
any person In any manner so as to became su odo mpen.ation Law.oAll roofs shall be inspected prior to any roofing material being-
fernie' //////�� ��,,00,,.. installed. If a roof is installed without first obtaining an
Date� / / <o/0 L Applicant inspection,I agree to remove all newmaterials for inspection.
NOT 66E�-TO AP#LLlcANT: if,after makln ka caruerffi.m Exemptwn,you should became Applicant understands and will comply with all non point
subject to the Workers'Compensetlonprovlelons of the Labor Code,you must forthwith comply PP P Y
with such provLslans or We permit shell be cameed revoked. Source regulations.
I certify that I have read this applkatlon and state that the above Information Is conect.I agree
ting
to comply with all city and county ordinances and state laws relato building construction,and All r f err t be class"C"or better.
hereby euthorloo representatives of this city to enter upon the above-mentioned property for In-
spectianpurposes.
(Ws)agree to save,Inderenity and keep harmless the City of Cupertino egalnse liabilities,
Judgments,mete and expenses which may in any way accrue against eadd City In consequence : .
of the granting of this permit. SIGN UR OF APPLICANT TE
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 -