R-6451 PERMIT
APPLICATION FOR CITY OF CUPERTINO NUMBER R"
INSPECTION DIVISION PE MIT EXPIRAT1
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 160 DAYS OF PERMIT ISSUANCE OR
BUILDING ADDRESS 160 DAYS FROM LAST CALLED INSPECTION.
�
11072-11112 Firethorne Drive
RESIDENTIAL % COMMERCIAL OTHER
OWNER'S Countrywood Homeowners Assoc. HAZARDOUS FIRE AREA
C/O Community Management -Services YES F] tlyes—lunderstendthata ClessA -
NAME roof assembly is required.
NO ❑ Initlel I.C.B.O.A
ADDRESS 727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
NUMBER OF EXISTING COVERINGS 1 (one) each
PHONE 408-395-9606 'Attn: Bob
CONTRACTOR'S
NAME Davey Roofing Inc- TO BE REMOVED- 1 TO BE RETAINED
ADDRESS 1 TYPE OF ROOF COVERING
22390 .Thunderbird Place, Hayward; CA 9454
CITY B ZIP
EXISTING .
PHONE 510-293-9300 BUILT-UP ROOF
SE
NUM ER 700710 ASPHALTSHINGLES El
LICENSED CONTRACTORS DECLARATION -
I hereby affirm that I em licensed under provisions of Chapter 8(commencing with Sect WOOD SHAKES 1z
7000)of DMskn 3 G the Business and Pmanu s Coda,and my license is In lull Mrs e
affect.
Uconse claeo C39 '72- D SHINGLES
Lk.Number 70071(1
Date cmnrector Davey Roofing, Inc. O (SPE ) h
OWNER-BUILDER Co tr DECLARATION PROPOSED Q p 11999
1 hereby affirm that am exempt from the Canny city License Lew M the browingantitreason. ��,1
(Sec.7031.5,Business and Prsh,or rns Code: Any dry pr county which re,also a requires
to PL
C—rfl applIcuct,or suh permitve,to file signed statement
he Is icanor to lta Issuance,to
quhea the BUILT-UP ROO [y
J of iffe Co for such permit to file a elpnetl r 9(commencing
that i Ilce cilc punterfto the prodel°ne
of the ContractarS Lkenea Law(Chapter hisex ptaref Section 7000)of for the 3 of the
ox
Business ptio entl violation of Code)or thet he le exempt therefrom and the bask for the scant to ASPHALT SHIN $
exemption.Any violation of Section hundred
by any eppllcent ler a Permit eublacle Me applicant io V
e cNll penalty of not more then five hundretl dollen(:WtX)).): 1
❑I,as owner of the property,or my employees with wages as their able compeneetlon,win do WOOD SHAKES ❑
the work,and the structure le not Intended or offered for sale(Sec.7044,Business end Pmlee-
cons Code:The Contractors License Lew does not apply,to an owner of property who bullde or 'WOOD SHINGLES ❑
Improves thereon,anti who does such work himself a through his own employees,provided that
such Improvements are not Intended a offered for sale.If,however,Me building or Pmprovem mt
is add within one year of completion,the ownenbulker will have the burden of profing Mat he did OTHER(SPECIFY) ❑
not build w Improve for purpose of eek J.
❑I,se owner of the property,em exdusWy,contreaing with Ikeneed ConlmGt0n9 to cMstmpl
the project(Sec.]046,Business ere Professio s Cade:The Contrectore License Lew dbas not PROVIDE I.C.B.O.REPORT NO.
"ply to an owner of property who bulks or improves thereon,and who contrecb M such projects
with a contreuor(e)licensed pursuant to the,Contractors Uterus Lew. PROVIDE MFGR. INSTALLATION SPECS.
❑1 em exempt under Sec. ,B 6 P.C.for Mb reason
Owner _ Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECI-IRATION
I hereby affirm under penalty of parlury one of the fallowing cKleretlon: �f
❑I hem and will maintain a Comficete of Consent to salbinsure for Workers Compensation, Building "
as provided for by Section 3700 of the labor Code,for Ma performance of work for which this $45,542.00
permit Is leaued. Seismic . S�
®I have and will maintain Workers Compensation Insurance,as required by Sectlon 370D of
the Labor Code,for the performance of the work for which the permit Is laeuetl.My Workers /� NQ
Compensatlon Insurance canter entl Policy number are: Total
carder California ComnensatioqAIbyNb. W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE - N.CQ
(This section need not be completed!11 the permit la for one hundred dollars($100)or less.)
I coldly that I the perfbrmaroe of Me work ler which permit la based.1 shall not am
any person In y ner so as to become w W a'2wipe.tM,Lawn a�au- All roofs shall be inspected prior to any roofing rnaterial being
Ierda. t installed. If a roof is installed without first obtaining an
Date Applkan. - inspection,I agree to remove all new materials for inspection.
NOT E AP LICANT: It,after making thisliterlificatis of Exemption,you arctic become Applicant understands and will tom with all non Dint
subject to the Workers'Compensation provisions of Me Labor Code,you must lord wish comply PP ply P
with such provisions or this permit nhal6be doomed revoked. source regulations.
I tartly,that I have reed this wpllcadon and State that the some Information Is correct.I spree
to comply with all rcityep and county of this cm,and stere lone the
ab to ,entll r di property
and < OOf. V AS t0 be CIBSS� r beneL - l/��
herebyspoolon pure ae representatives of this city to Doter upon.he ebwro-menaorretl property for In. �� /
f (We)agree to save,Indemnify entl keep rurmbes Me City of Cupertino a Inst Ilabllith", �T f�
ludgmanb,c°sb entl e.penaes which may In any way accrue against said Gry n coneequerxs t G TU E OF APPLICANT D ��
of the rantin of Mle 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY