R-6449 ERMIT
APPLICATION FOR CITY of cuPERTINo
NU BER R6449
INSPECTION DIVISION PERMITEXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WTTHIN 180 DAYS OF PERMIT ISSUANCE OR
180 DAYS FROM LAST CALLED INSPECTION.
l� BUILDING ADDRESS
20531-20551 Shady Oak Lane
Cupertino, CA RESIDENTIAL_X_COMMERCIAL OTHER _
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS FIRE AREA
'c/o Community Management Services YES ❑ Ifyes–IunderstandltrataClassA
NAME Y g roof assembly is requited.
NO ❑ Initial I.C.B.O.Y
ADDREss 727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
PHONE _ _ - NUMBER OF EXISTING COVERINGS 1 (one) each
Bob Soars
CONTRACTOR'S
TO BE REMOVED 1 TO BE RETAINED
NAME DavB X Rrj,o£ing, IAC
ADDRESSTYPE OF ROOF COVERING
CITy6ZIP 22390 Thunderbird Place, Hayward, CA - 94545 EXISTING
PHONE 510-293-9300 _ BUILT-UP ROOF ®f
LICENSE 700710
NUMBER ASPHALTSHINGLES ❑
LICENSED CONTRACTORS DECLARATION
1 hereby affirm that I em licensed under provlelone �R of Chapter B(commencing with Search WOOD SHAKES lid
7000)of Drdslon 3 of Me Business end Professions Code,and my license is In tug force end
ehact. 0 HINGLES
Ucemse Class C39 Lie.Number 700710 ❑
Date Contractor Davey Roofing, Inc. OTHER(SPECIFY) . ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby eHBuirm that I am exempt from the e: Any chly License Lew for re uires following lessen.ixtto
(Sec.7ct,aft Business and Protaeeans Code: Any 0lty a aunty which re,am a uirest to
applic0 0
construeL shah Improve,demolish,a signed
d sta any statement
hurt e,prior m e issuance,ant to requires Ura BUILT-UPR [�
of the
tr such permit a Ills a sigred r 9(comm that g i tic echo pursuant to Me proNef pre
of the Contractor s LVicenae Lew(Chapter B(cammeralrg with Section 7000)of Division 3 0l tie
. Buelresa am Prolesetons Coos)or that he Is exempt therefrom and the basis for the ellegeo ASPHALT SfJr7' GLEWR `� 1 9
exemption.Any vlolatla of Section 7031.5 by any eppllcant for a permit subjects the appllant to
e clvll penalty of not more than five hundred dollars(5600).): WOOD SHAI,ee ownerof the property,or my employees with wages as their says compenation,will de the rork.entl the structure le not Intemsed or ohered for sale(Sec.70th,Business and Proles-alone Code:The Contrectora License Lew does rat apply to en owner of property who Wilde orWOOD$HI
improves thereon,as who does such work himself or Ihmugh Na own employees,provided Mat
such Improvements are not Intended Or offered lar sale.It,however,the bulltling or Improvement
is sold within ars year of completion,the owner-wilder will he"the burden of prodw that he dm OTHER(SPECIFY) ❑
not build or Improve for purpoea of sale.).
❑I,ice owner of the property,em exduaInty contracting with llcenaed contractors to anatruct /"
the project(Sea.704,Buelnese end Professions Code:The Cantrector'e Laenae Lew does not PROVIDE LC.B.O.REPORT NO.
appy to an owner of property who builds or mortes thereon,and who contrecte for wchr projects,
with a antrectons)Ikamed pursuant to de Contractors Ucanse law. PROVIDE MFGR.INSTALLATION SPECS.
❑1 em exempt under Sec.. ,B 8 P.C.for thio reeam
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under perulty of Penury ons of Ute following oecleration:
❑ ve
I haand will maintain a Cerhllon,hcate of Content to sell-Insure lar Workers Compensa Bldln
ice provided far by Sedan 3700 of NM
e Labor Code,for e performance Ul
ce of the work or which this - g�/ g
permtla Issued. / • Seismic (0
wIe maintain Workers Compensation Insurance,as required by Setllon 3700 of `
„Me labor Cae,for the penormil of the work:fa which this permit Is Issued.My Workers
Compensation Insurance caller and Policy number are: Total
CarriwCalifornia CompensatioNilcyNo. W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C.❑
(This section need not be completed If Vic Permit Is for one hundred dollars(5100)or see.)
I ctubty Drat In Me padomrrarae of the work for which this permit Is Issued.l shall not amvaY
any person In my manner so as to beame sublect to the W Compeneanon Laws of Ceti- All roofs—sing be inspected prior to any roofing material befing
installed. If a roof is installed without first obtaining an
Date Applicant .CLQ �—' inspection,I agree to remove all new materials for Inspection.
NOT] TO AP CANT: 11,after mekln5this berri of Exemption,you ehouitl beams Applicant understands and will with all non
prov
subject to the Workers'Companaatlon rovislom of the Labor Cade,you must IorthwM complypP comply P Y P
with such takxu or Mia permit ehel�bke
e aeemed revod. Source regulations.
I certify Mat I have read MIs applicadon and state that the¢Wove Imormalbn Is ccrre Iagree '
to amply with all dry and county ordinamoss and state laws rele0ng to Wilding arotrudbn,and All roof cover1r;aq to be class"C"or better.
d hereby authorize represontatihes of this city to enter upon Me above-mentioned properly for In-
spection
n- pp
I aped e)agree to
(We)agree le sane,Indemnify ly end keep harm ase the Clry of st*aCuparflno against IIeWIIIHee, LU/J
judgments,of
costs tamdhis expenses which may In any way accrue egalnat seltl.Gty In arreequerae
of the granting of Wa Parrott SI N TURE OF APPLICANT ATE
• 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