R-6440 PERMIT R_
APPLICATION FOR CITY OF CUPERTINo NUMBER 644
0 .
y INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 190 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM UST CALLED INSPECTION.
BUILDING ADDRESS
20604-20634 Maple Tree Place
Cupertino, CA RESIDENTIAL—X—COMMERCIAL - OTHER
OWNER'S Countrjwood Homeowner Assoc. HAZARDOUS FIRE AREA
c/o Community Management Services YES ❑ oyes-I understand that a Class
NAME " y g rod asserNlly is required. '
95030 No ❑ Intel LC.B.o.a
'ADDRESS
727, University Ave. , Los Gatos, CA EXISTING ROOF COVERING
NUMBER OF EXISTINGCOVERINGS 1 (one)each
PHONE
CONTRACTOR'S
NAME Davey Roofing, Inc. TO BE REMOVED I TOBERETAINED
ADDRESS TYPE OF ROOF COVERING
CITYazIP 22390 Thunderbird Pl. , Hayward, CA 94545
EXISTING ,
PHONE 510-293-9300 BUILT-UP ROOFLICENSE
�]
NUMBER 700710 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
. I hereby affirm that I am licensed under provlebre of Chapter 9(commencing with Section WOOD SHAKES -
7000)of Division 3 of the BuMnew and Prof salons Code,and ny Ilcensa Is In full fart
effect' WOOD SHINGLES El
Ucense Class C39 Lk.Number
Davey Roofing, Inc. OTHER(SPECI n
Date Comsdor D
OWNER-BUILDER DECLARATION
I hereby affirm,Met I em exempt from the Contracto(e License Lew for the following M.. ��� � � ���^y
(Sec.7031.5,Business and Professions Code: Any city or county which requires a permit to
Wnsbucq after,improve,demoksh,or repair any simcture,prior to Its Issuance,also requlrae the BV U P ROOF
eppecent for such permit to Me a signed statement that he is Ilcenead pursuant to the provisions _
of IM Contractors License Law(Chapter 0(commencing with Section 701 of Divlelon 3 of the
• Butunums and Protevabts Code)or that he Is exempt Marefrom and Me basis for the alleged ASPHALT SHING
exemption.Any violation of Section03
71.5 q the any applicant for a Permit subjects applicant to Y
e dull penaly of not more than five hundred dollars($500).):
C]1,u owner of the property,or my employees with wages as their sale compensation,will do WOOD SHAKES ❑
the work,and the structure Is rot Intended or offered for sale(Sec.7044,Business and Proles-
alone Code:The Contractors License law does not appy to an pwror of property who builds or WOOD SHINGLES '
Improves thereon,and who does such work himself or through his own employees,prodded that El
uch
sImpm
roveents are not Intended or offered for sale.If,however,Me bulbhg or Improvement
Is gold within one year of completion,the owner-wiser cal 11 have the burden of proving that he and OTHER(SPECIFY) ❑
not build or Impri for purpose of seb.).
❑I,as owner of the Property,em exciueNely contracting with licensed contractors to construct
the project(Sec.71N44,Business and Professions Code:The Contractors License Law does not PROVIDE I.C.B.O.REPORT NO.
appy to an owner of property who police or Improve thereon,and who Wntrects for such projects
w1th a contrador(s)Iicaneed pursuant to the Contractors License Lew. PROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C.Or this reason.
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECIJdiATION
I hereby affirm under penalty of perjury one of the o owing dociamdon:
1 have antl will mountain a Certificate of Consent tc setl-insure for Workers Campecaatlon, Building
as provided for by Sectkn 3700 of the Labor Code,for the performance of the work for which thle
permit Is Issued. 931• Seismic
7[L have and will maintain Workers C the work
W insurance,as perequiredsu Section or of /
the Lebon Cada,for nc performance of the work lar which this perrNt b Issued.kiY Workers Total
Cgmpensatkn Insurance carrion and Pdloy number are "
Center California Compensati001,yNq W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE INCE)
(This section need rot be completed etetl If pertNt Is for one hundred dollars($100)DO)or lees.)
I cart ty that In the whormarwe of the work for which this Permit is Issued.I shell not emPlq
any Person Ina y manner as to become suojed to} a We are'Com eneatlon Lowe of Cali- All roofs 9hall be inspected prior to any roofing material beiAg
Mrnia. ( installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
NOTI TO ADPL CAM: It,after makinrffig Car to of Exemption,you should become Applicant understands will I with all Int
subject to the Workers'Compeneatlon pro Talons of the Labor Code,you most forthwith comply - pp s ancomply y non I�
with such provisions or this Permit shell pe, eem
ded revoked. source regulations.
I tartly that I have read Na application and state that the above Information is correct I agree
to comply with all city and county ortlbanoes end state Iowa roofing to building const and All f to be class"C"or better.
hereby authorize repreeenletivee of this city N anter upon the ebavamentloned property for In. 1
epeen purposes
(We)agree to save.Indemnity and keep henmlesa the City of Cupertino against Ilebllltiee,
judgments,Wine and expenses whkh may In ad.way accrue against said Cly In Wnee411— SIGNATURE OF APPLICANT DATE
of Me grenllrg of trues permit.
• PRE-INSPECTION: PLYWOOD: IN-PROGRESS:
INSP. DATE INSP.- DATE INSP. • DATE
TEAR OFF INSPECTION: BATTENS: FINAL:
INSi DATE INSP. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY