R-6444 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6 4
INSPECTION DIVISION PERMITEXPi R.AT10N
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 150 DAYS OF PERMIT ISSUANCE OR
.. 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11107-11119Flowering Pear Dr.
Cupertino, CA RESIDENTIAL X COMMERCIAL OTHER
OWNER HAZARDOUS FIRE AREA
ountrywood Homeowners Assoc. YES ❑ If yes—I Lalderstend that a CassA
NAME c/o Community Management Services roof assembly is required.
NO ❑ Intel I.C.B.O.F
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
ADDRESS TYPE OF ROOF COVERING
cITYazIP 22390 Thunderbird Pl. , Hayward, CA 94545
EXISTING,
PHONE stn-99g-9znn BUILT-UP ROOFLICENSE
§]
NUMBER 700710 ASPHALT SHINGLES El
LICENSED CONTRACTORS DECLARATION
I hereby affirm that I em licensed under provlelons of Chapter 9(commencing with Section WOOD SHAKES {]
7000)of Division 3 of the Business ark Professions Code,ark my license le In full force and
effect. WOOD SHINGLES
License clan C39 Us.Number 700710 ❑
Date Cmbactor-D3uejc--ROO.fino_o� T* r_.� OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
I hereby affirm that I em exempt from Ne Contractors Ucenee Lew for Ne following reason.
.(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
construct,eller,Improve,demolish,or repair any structure, rfor to aIssuance,also requires Inc BUILT-UP ROOF
applicant for such permit to Ills a dgned statement that he Pa Ikenseci pursuant to the provisions
of the Contractors Useful Lew(Chapter 9(cammencing wwh Section 71100)of Divalon 3 of the
• Businee entl Professions Code)w that he Is exempt Iherelrom and!the basis for the alleged ,ASPHALT SHINGLES �]
exemption.Any violation of Section 7031.5 by arty applicant far a permit subjects the applicant to
e civil penalty of not more than No hundred dollen;(5500).): WOOD SHAKES
7]I,as owner of the property,or my emplayeas with wages as their able compensation,will do ❑
the on,and the structure is rot Intended or offered for sale(Sec.7044,Business and Prates-
. stone Code:The Contractors License Lew does not apply to an owner of property who bunds or WOOD SHINGLES ❑
Improves thereon,and who cceeach ework himealt or through his own employees,provided that
such Improvements are not Intended or offered for sale.If,however,the Wilding or Inprovmyent
is sold within one year of completion,me owner-butter ww have the burden of proving Met he did OTHER(SPECIFY) ❑
not build or Improve for purpose of sale.).
❑I,es,owner of the property,em exclusively Parmesang with licensed conire(.Yore to construct
the project(Sec.7044,Business end Professions Code:The Contractors Uceme law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds or Improve thereon,and who comrade for such protects
with a contractods)licensed pursuant to the Contractor,License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following self4 declaration: y • LLKI 11 C
❑I have and will maintain a Certificate of Conner to eperNitre Ion Workers Compensation,
as mit Is I d far by Section 3]OD of the Labor Code,far the perbrmerce of rhe work for which th4
Permit is Issued. $6 �
g I have and will the performance
Workers Compensation Insurance,as required by Section. y37110 0l / ��1999fff777111111
the Labor Coda, ur the p enter ance of the work for which this permit Is Issued.My Workers
Compensation Insurance carder end Polley number are:
Carver California CompensatitpmLgyr4o, W98S171591 PERMIT AUTHORIZATION DAT
Iff
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed if the permit is br orro hundred dollen(5100)or lave.) ,
.. I certify that In the performance of the work for which this perp t is Intrad, shell not employ
any parson In mann w e to became eubled n War a cam etbn Lawn of call-. - All roofs shall be inspected prior to any roofing material being
forma. installed-If a roof is Installed without first obtaining an
Date �� Applicant' inspection,I agree to remove all new materials for inspection.
E TO PUCANi: II,after making Mf ertni a of Exemptlpn,you should become Applicant understands end will comply with all non oint
sublebr to the Workers'Compersatkn provlekxs of the Labor Code,you must forthwith comply, PP P Y P
with such provialom or this Permit shell be deemed revoked. source regulations.
I cartlty that I have read this application and state that the above Information is correct 1 agree
to comply with all city and county ordinances and area lawn raffling to building construcllon,end AIIr fl t0 be class 6 or better
hereby authorize representatives of this city to enter upon the above-menlloned property for In-
(We)sprees save,Ndemnwy and keep harmless,the City ai Cupertino against Ilabi ul 7 777
ludpmenta coots ane expenses which may m arty way acorns against said Gry In consequence �j jATUR OF APPLICANT
of the gr EC of this permit - _
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