R-6453 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER .
INSPECTION DIVISION - PERMIT EXPIRATION
REROOF PERMIT (408)777-.3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
190 DAYS FROM LAST CALLED INSPECTION..
BUILDING ADDRESS
11041-11061 Firethorne Drive
RESIDENTIAL X COMMERCIAL OTHER
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS FIRE AREA
d VES ❑ If yes-I understand flat a Class A
NAME c/o Community Managelfient Services - rodassemblyisrequired.-
' - - NO ❑ Initial LC.B.O.B
ADDRESS 727 University Ave„ Los Gatos. CA 9503 EXISTING ROOF COVERING
PHONE
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
CiTY.a ZIP 22390 Thunderbird Place, Hayward, •CA '-9454
EXISTING
PHONE 510-293-9300 -
BUILT-UP ROOF
LICENSE
NUMBER 700710 - - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby aHlrm that I em licensed under prWsbrs of Chapter 8(commencing Seal WOOD SHAKES
7000)of DMsim 3 of Me Business and Professions Code,and my license b In full force and - _
e"� OD SHINGLESEnm �.
scenes class C39 Uc.Number 700710
Davey Roofing, Inc.. THER(SPECIFY)
Date Contractor •r
OWNER4BUILDER DECLARATION PROPOSED N .0I 1991
I hereby allirm Thal I am exempt from the Contractor's License Lew fo"following reason. 9
(Sec.7031.5,Busness and Prolessiorvs Code: Any city o county which requires a permit to
construct,alter,improve,demolish,or repair any structure,prior to Its Issuance,also requires the BUILT-UP ROOF
applicant for each Permit to IIIA a signed statement mat he Is ticensed pursuant to the phrAsioms
of the Contractor',License law(Chapter a(commencing with Section 7000)of DlvIson 3 0r'Me
• Business and Professions Code)or that he Ie exempt therefrom and the basis for the alleged ASPHALT SHINGLES
exemptlon.Any violation of Seclion 701.5 by any applicant for a pemdl subjects the eppllcant to
e WI penally of not more man Ne hundred dollars(5500).):'
E]1,as owner of me property,or my employees with wages as their sets compensation,will do WOOD SHAKES ❑ .
the work,and the structure B root Intended or offered for We(Sec.7044,Business and Proles-�
-
ebTM Contractors TContractors Lkenso law does not apply,to an owner of property who builds or WOOD SHINGLES ❑
Improves erereon,eros who does such work himself or through his own arosoyass, roWCee mat
such Improvements are not Intemded or offered for sale.If,however,the Wilding or Improvement
Is sold within we year of completion,the ownerqullder will have the burden of proving that he diff OTHER(SPECIFY) ❑
not Wlld or Improve for purpose of sale.).
❑I,as owner of the property,am exclusively contrecdwim licensed comractore to construct
the project(Sec.7044,Business and Professions Code:The Contractors License Law case not PROVIDE I.C.B.O.REPORT NO.
.appy to an owrrer of property who bullcs or Improves thereon,and who contracts,for such projects
with a cootrecer(s)Ikensed pursuant to the contractors License Law. PROVIDE MFGR. INSTALLATION SPECS.
1 am exempt under Sec. ,B 6 P.C.for this reason
Owmer Data
WORKER'S COMPENSATION DECLARATION APPLICATION DATE VALUATION PERMIT FEE
I thereby affirm under penalty of perjury arra of the following declaration: F�
Q I have and will maintain a Carilecate of Cmis nt to wlf-Insure for Worker's Compensation, Building
J
as provided for by Section 3700 of the Leber Code,for the performance of the work for which this g
permit la Issued,
have and will maintain Workers Componsadon Insurance,as required by Section 3700 of - $45,542.00
JUSeismic
ihr Code,for the performance of the work for wfib fe
lch this permit suetl.My Workers
Compeneatl m Insurance carrlar and Policy number are: Total
Carter California Comoensatiqp,,yNpW985171591 PERMIT AUTHORIZATION ;)ATE
CERTIFICATE OF EXEMPTION FROM WORKERS' A
COMPENSATION INSURANCE N.C43 /
(This section need not be completed If the permit is for ma hundred dollars($100)or less.)
I tardy,dsl In the performance of the work far which,ihie II Is Issued,I,halt not employ
any perso011nneir so es to become t to Iia pensadon Laws of call- All roofs shall be.inspected prior to any r ng aterial beingtofre installed. If a roof is installed without first obtaining an
oeta Applicant .inspection,I agree to remove all new materials for inspection.
NO ANT: If,alter mall thkCartilkite of Exemption,you should became Applicant'understands and will comply with all non point
subject to the Workers'Comperral provisions of the Labor Cob,you must tWhwim comply
wim such proWebns or this peso t BMID. a deemed revoked. - source regulations.
I wMty It I have read thle appikation antl state that Me above Information is correct.I agree
to comply wish AN dry and county ordinances and state laws ndeting to Wilding construction,aM All roof CO nn obe class" better.
hereby authorize representetiv®s of this city to enter upon the atx a nnendmad property for In-
specton purpose,. /
(We)agree to save,Indemnity mod!keep harmless Me City,of Cuperdrw agalnel liabilities, �- �'
Judgments,costa and expenses which may In any way accrue agenel sell Cly In consaquenca SIGNATURE F APPLICANT D E
of the granting of Mi,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 ACCESSTO ROOF SHALL BE PROVIDED.FOR INSPECTION
OFFICECOPY -