R-6452 PERMITR_ 6452 .
APPLICATION FOR CITY of CUPERTINO NUMBER
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT
(408)7-/7-'3'222 8 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 1W DAYS OF PERMIT ISSUANCE OR
`.• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
20556-20578 Cedarbrook Terrace X
- - RESIDENTIAL COMMERCIAL OTHER
OWNER'S RE
C
°9untrywood Homeowners Assoc. . YES E] Byes-lunderstandthetaClassA
NAME °Community Management Services roof assembly is required. -
NO ❑ - In tial I.C.B.O.Y
ADDRESS 727 University Ave- Los Garnc rn 95030 EXISTING ROOF COVERING
PHONE
408-395-9606 Attn: Bob Soars NUMBER OF EXISTING COVERINGS 1 each
CONTRACTOR'S
NAME Davey Roofing, Inc. TO BE REMOVED 1 TO BE RETAINED 0
ADDRESS TYPE OF ROOF COVERING
CITY&zip 22390 Thunderbird Pl, Hayward. CA 94545 EXISTING .
PHONE 510-293-9900 BUILT-UP ROOF
LICENSE
NUMBER 70071U ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION
I hereby affirm Mel 1 am Ikensad under provisions of Chapter 9(cemmenefng wIM Section WOOD SHAKES �C]
7000)of DMslon 3 of Me Business and Profesebns Coda,end my license le In full tree and
effect. D INGLES
Licenes Clew C39 Lb.Number 700710
Data Contractor
Ravey—R°ofing, Inc OTHE (SPECIFY) D (�
OWNER BUILDER DECLAR! PROPOSED JUN 011999
I hereby allirm Met I am exempt Iron the Contrector'e Ucerum Lew for Ne foltxing reason.
(Sec.7031.5,Business and Professions Cade: Any city or county which requires a permit to
construct,alter,Improve,demolish,or repair any structure,prior t he Issuaroro,aim requires Ma 'BUILT-UP ROOF I]
applfoant for such permit he HIS a signed statement that he Is licensed pursuant to Me provisions
of Me Contrector'e License Lax(Chapter a(oommencing wI h Section 7000)of Mvison 3 of the
.• Business ars Prcfemirns Code)or Mat he is attempt Iherebom era the basis for the alleged ASPHALT SHINGL By
exemption.Any violation of Section 7031.5 by any applicant for a parmn aubjects the applicant to
a civil penalty of not more then Ilve hundred dollars(5500).):
❑I,as owner of Me property,or my employees with wages a,Meir sole compensation,will do WOOD SHAKES ❑
the work,entl the structure Is not Intended or offered for sale(Sec.7044,Business and Profen
dons Cade:The Contractere License Law floes not appy to an owner of property who bullde or WOOD SHINGLES ❑
Improve,thereon,end who teal Such work himself or through his own employees,provided that
such Improvements are not Intended or offered ler sale.It,however,the Wlaing or Improvement
is sold within ona year of completion,the owner-builder will have Me burden of proving Mat he did OTHER(SPECIFY) ❑
not I or Improve for purpose of Sale.).
I,as owner of the property,em exclusively contracting with Ilcersed contractors to construct '
Me project(Sec.7044,Business and P ofessfons Code:The Contractor's Llcwm Law does not PROVIDE I,C.B.O.REPORT NO.
apply to an owner of property who leu llds or Improves thereon,and who contracts for such projects
with a contmctons)licensed puns m to the Contractors llcenaa Lew. IPROVIDE MFGR.INSTALLATION SPECS.
❑1 am exempt under Sec. ,B&P.C,for INS reason
Owrsr Aare
WORKER'S COMPENSATION DECLAMnON APPLICATION DATE VALUATION PERMIT FEE
I hereby affirm under penalty of perjury we of the following declaration:
❑I have and will maintain a Cerftlbate of Consent to SeMlneurs for Workers Compensator, Building
��•
as prWiled ler by Section 3700 of the Labor Code,for the performance of tiMI
s work for which S
Permit is Issued. 45,542.00 Seismic
Drl have and will malnten Workers Compensadon Insurance,as required by Section 3700 of
the Labor Code,ler the performance of the work for which Ws permit Is Issued.My Worker's
Compensation Insurance caller and Policy number ere: Total
carder California ComoensatianlloyNo. W9951715Q1 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE IN C,O '
(This Section need not be completed n Me permit Is for one hundred dollars($1 W)or lave.) /
I tartly Mat In a performance of the work for which thy permit Is Issued,I shall not employ - -
em person In a man ao ea to become au tot Yorke C he anon Laws of Call. All roofs shall be inspected prior to any roofi tenal being
forma. / /�/ installed. If a root is installed without first obtaining an
Date ( / ApWm�nt inspection,I agree to remove all new materials for inspection.
Non ro Ia ANTComps,anon maks r*Lal fools,youu Mus fo�o�Pry Applicant understands and will comply with all non point
Subject the Workare Com nsatlon ruisbn ate Labor Cade,
wIM s provleons or MLS permit Shall be deemed revoked. source regulations.
I eerily that I have read MLS application and state that the above Information Is correct.I agree
to comply with ell city era county ordinances and state leve relating to Wilding constructlon,and All roof seri tobe class" or better.
hereby authorize representatives of INS city to enter upon Me eWva-mentlened property ler In-
apection purposes. "
(We)agree to save,Indemnify and keep harmless the City of Cupertino against Ilabllillee,
IudgmenIS,coat,and expenses which may In any way accrue agehet sold Gy In consequence
• of Me gmnung of Illds peon d. S G TORE OF APPLICANT AYE
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