R-6438 CITY OF CUPERTINO PERMIT
APPLICATION FOR NUMBERR_ 6438
REROOF PERMIT. INSPECTION DIVISION �,.EXPIRATION
(408)M-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 18th DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
20644-20674
Maple Tree Place, Cupertino, CA RESIDENTIAL R COMMERCIAL OTHER
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS FIRE AREA
YES It yes–I understand Mat a Class A
❑
NAME c/o Community Management Services roof asvernayisrequired. .
NO. FIInitial I.C.B.O.Y
ADDRESS 727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
PHONE 408-395-9606 Attn@.' Bob Soars
NUMBER OF EXISTING COVERINGS I each
CONTRACTOR'S '
TO BE REMOVED 1 TO BE RETAINED
NAME Davey Roofing Tnr. ...
ADDRESS TYPE OF ROOF COVERING
CITYanP 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 met I em ticrmsed under provisions of Chapter a( ,mmencin WOOD SHAKES
7000)of Division 3 of the BUMnem and Professions Cade,end my Ilcenae b In lug force
effect.
License0rsm C99 WOOD SHINGLES ❑
Uc.Number �nn7ln
DateCorrlrecfo,Dayey Roofing, Inc. ER(SPECIFY) ❑-
OWNER-BUILDER DECIARATION (��
I hereby affirm that I em exempt ham the Contractors License Lew for the lollowtrg rester. PROPOSED f ��'�\
(Sec.7031.5,Business and Profemlans Code: Amy city or county which requires a permit to Z_—
construct,after.Improve,tlemollsh,or repel any structure,prior to Ile Issuance,also requires the BUILT-UP ROOF '-II Q D
eppllcent for such permit to Me a agnetl statement that he le Ilcenmtl pureuent to me provWons APR L,U 1999
of the Contractors License Law(Chapter 0(commencing with Section 7000)of W Talon 3 of the LL3 of the 'r ➢➢
Business end Professions Code)or that he Is exempt therefrom and the bears fon the alleged ASPHALT SHINGLE u
exemption.Any violation of Section 7WI S by any spp'Icam for a permit subjects Ne applicant to J
e dull peoefy of not more then five hundred dollars($500).):
❑I,as owner of Na property,or mry employees with wages as their ads compensation,will do WOODSHAKES ❑
the work,and the structure Is not Intended or offered for safe(Sec.7044,Business and Prefers By
alone Code:The Contractors Ucsnm Lew does rot appy to an owner of property who builds or WOOD SHINGLES
Improves thereon,and who does such work himseff p through his own ampioyses,provided Net
Such Impmvementa are not Intended or offered for safe.If,however,the Wilding a Improvement
Is acid vd Nn aro year of completion,the owner4nllder will have the burden al Proving bet he dd OTHER(SPECIFY) ' ❑
not dtlb or Impove for purpose of Sale.).
❑I,as owner of the property,em exclusively contrastwith licensed contractors to construct
me pngect(Sec.7044,Business and Profeeabru Core:the Contractors Ucenee Law does raft PROVIDE I.C.B.O.REPORT NO.
epPNtoen owner of property wM Wlos or improver;thereon,and who cornmols for ouch Pro)"
with a contrectora)licensed pursuant to the Contractors Ucense law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 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 penefty of perjury one of the following decrsredon: _ r'e
❑1 he"and win maintain a Cerhfbaa of Consent to mft4nsure for Workara Compeneetion, Building
V
as provided for by Section 3700 of the Labor Cade,for the performance of the work for which thle p g
permit Is have
aIssued. j 3�. Seismic �"f
�] have entl will maintain Workers Campo ori for Insurance,po required by Sedloa 3700 of
the Labor Code;for the performance of the work tar which this permit rs issued.My Workers
Campenmtlan Insurance carrier end Policy number are: Total
CemrsrCalifornia Compensatio%1yNp.W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE . N.C.p
(This section need not be completed It the permit to far one hundred dollars($100)ar tem.) y✓/
I ceNy Net In the performance of the work for this pp Is Issued I shell not son loy
any thereon n manner m m to become tube o e W o rt'c«npenmticn Lowe a dell. All roofs shall be inspected prior to any roofing material song
fomia. installed. If a roof is installed without first obtaining an
Data q/ Apiall inspection,I agree to remove all new materials for inspection.
suge�U to thio�ro� If,aftermalting In Of the c*ue"b of Fxyou ,you rte d Caroms Applicant understands and will comply with all non point
with such provlskxm W Out ppermrit drall provisions
e deemed reevoked.r Caere,e,you must brVtwlth comply, source regulations.
I sanity that I have read nL5 epplicatbn end trate that the above Information Is comed.I agree
to comply with ere city and ccu ntyordinenc r,and Stere bwt relating to WIINng comsmxc on,end All r of 'e 'n s to be Gass"C"or better.
hereby euurpos repentntetWes of Mrs dry to enter upon the above-mantbnetl properly for Ir~ �
ep(We) purport.
(We)spree 10 save,Indemnity end keep harmless ywaytion Cly of Cupertino against Ilei-ne
Judgments,coats and eapenms whim may In any way aware against sae Cly In wneequence
• cit eprantinpofihrspermx. SIGNATURE 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 -