R-6439 PERMIT R- 6439
APPLICATION FOR CITY OF CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRArnnN
REROOF PERMIT (406)7.77-3226 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
160 DAYS FROM UST CALLED INSPECTION.
'BUILDING ADDRESS
20595-20617 Maple Tree Place
Cupertino, CA RESIDENTIAL X COMMERCIAL OTHER
'OWNER'SHAZARDOUS FIRE AREA
Countrywood Homeowner Assoc. YES ❑ If yes—I understand that a Cls, A
NAME c/o Community Management SPrvi CPR rod assembly is required.
NO ❑ Initial I.C.B.O.N
ADDRESS 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 TO BE REMOVED - 1 TO BE RETAINED
NAME Davey Roofing, Inc.
ADDRESS TYPE OF ROOF COVERING
cITYBzIP 22390 Thunderbird Pl - -Ha •;card CA 945L5 EXISTING
PHONE 510-293-9300
BUILT-UP ROOF
UCENSE
NUMBER 700710 ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES
7000)of Division 3 of the Buelness end Professions Coda,and my license Is In lull force and
affect. WOOD SHING z
Ucense class C39 Uc.Number 700710 0
Date Contractor Davey Roofing, Inc. OTHER(SPE
ION
I hereby affirm that I am axe
OWNER-BUILDER
the Contractors LI ense Law for the following reason. p D APR 16 1999
(Sec.7031.5,Business and Professions Code:,Any Gly or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior to 4e Issuance,also requires the BUILT-UP RO F
apolcant for such permit to file a signed statement that he a licensed Pursuant to the provisions
• of the Connectors Licenae Lew(Chapter S(commencing with Section 7000)of Dlvlebn 3 of the B
Business and Profess{ns Code)or that he b exempt therefrom and the baao for the alleged ASPHALT SHI
exemption.Any vlolaHon of Sectlen 7031.5 by any applicant for a permit subjects the applicant to
e dvll penalty of not more than five hundred dollars($500).):
❑I,as owner of the property,or my employees with wages as their sole compensation,will do WOOD SHAKES ❑
Me work,and the structure Is not Intended or offered for sale(Sec.7044,Business and Profss-
sone Code:The Contradu s License Law does not apply to an owner of property who Wiles or WOOD SHINGLES El
maroon,and whe does such work himself or through his own employee ,provided that
such Improvements are not Intended or offered for sale.It,however,the building or Improvement
Is sok wlMln one year of completion.Me will have the burden of proving lief he dd OTHER(SPECIFY) ❑
not bulk or Improve or purpce,of sale.).
❑I,as owner of Me property,em exclusively canbactir g with licensed contractors to construct
the Project(Sec.704,Business and Professions Code:The Contractors Lkerne Law cols rat PROVIDE I.C.B.O.REPORT NO.
app to an owner of property who builds or Improves thereen,"who connects for such projects
with a contrador(s)Ilcansed pursuant to Me Contractors License Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑I em exempt under Sec. ,B b P.C.for this reason
owner Data -
WORKER'S COMPENSATION DECUBATION APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penally al perjury one of the IollmHng dedamton:.
-11 have and will maintain a Certificate of Consent to self-Insure lex Workers Compensation, /// Buildin
es provked ssfor by Section 3700 of the Labor Code,for Me performers of the work or which Ws ����% g
permit is Iued.
Rl I have and will maintain Workers Compensation Insurance,as required by Section 37M of / Seismic
—Me Labor Code,for the performance of the wcm for which Iib Permit Is Issued.My Workers
Cwnpmeaton Insurance carrier and Policy number are Total
carom California CompensatiqDcyNo,W9R5171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C{]
(This section need not be completed r the permit Is for one hundred dollars(5100)or foss) ^J
I canny that In the performance of the work for wit MIs pernnt Ie Issued,I Melt rot emvkry
any person In mvmer es to be eu oro ro compensatlon Laws of Ceu- All roofs s all be inspected prior to any roofing material being
fornix. installed. If a roof is installed without first obtaining an
Date G Awl am inspection,I agree to remove all new materials for inspection.
NO TO APP CANT: If,after makkW M Cent to of Erennl ton,you should become Applicant understands and will comply with all non point
subject to the Workers'Compensation provlelms of Me Labor Coda,you must forthwith comply pP P Y P
with such provolone or mis permit shelr be Warned revoked. Source regulations.
I ceNly Met I have read this application and state that the above Information le correct 1 agree
to comply with all city and county ordlnences and state laws relating to building crosmu m,and All ro o9yeringislo be class"C"or better.
hereby auUwrze representatives of this city be anter upon the above-montona l property for In-
spection Purposes. /
(We)agree isave,Indemnity and keep harmlessyway the City of Cupertino epelnat IkNlltlss, �7 /
judgments.granting
costs end expenses which may In anyway accrue egslnat sold City In consequerke 7
of the grenung a this permit SI(pNQI UR DF APPLICANT DATE
PRE-INSPECTION: PLYWOOD: 1N-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