R-6443 APPLICATION FOR CITY OF CUPERTINO
rPiu seR R- 6443
INSPECTION DIVISION .P RMIT XPIRATI N
REROOF PERMIT (408)777-3228 : PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
• 180 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11077-11099 Flowering Pear Dr.
Cupertino, CA - RESIDENTIAL X' COMMERCIAL OTHER
OWNER'S' Countrywood Homeowner Assoc. H RDOUS FIRE
NAME c/o Community Management Services YES.❑' Id a-lucier ly is IIataC1aESA
NO ❑ It" I.C.B.O.P
ADDRESS 727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
PHONE 408-395-9606 Attn: Bob Soars '
NUMBER OF EXISTING COVERINGS 1 (one) each
CONTRACTOR'S
NAME Davey Roofing, Inc. TO BE REMOVED 1 TO BE RETAINED 0
ADDRESS 22390 Thunderbird Pl. , Hayward, Ca 94545 TYPE OF ROOF COVERING
y
CITY&ZIP
EXISTING
PHONE 510-293-9300 - BUILT.-UP ROOF
LICENSE
NUMBER 700710 - ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby efnnn that I am licensed under provisions of Chapter B(commencing with Section WOOD SHAKES ]G
7000)of Division 3 of the Business and Professions Code,and my license Is In full bice and -
effect.
LicenseCl. C39 Uc.Number 700710 WOOD SHINGLES El
Date Ccatrector Davey Roofing, Inc. OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION I PROPOSED
I hereby affirm that I am exempt from the Contractor's Ucense law Or the following reason.
(Sac.7031.5,Business and Professions Code: Any city or county which requlma a permit to
construct,after,Improve,demoliah,or repair any structure,p Iorto Its lssuence,also requlres me BUILT-UP ROOF ]
applicant for such permit to file a signed statement that he Ie licensed pursuant to the provislons
of the Contractor's License Law((Chapter 9(commencing with Section 7000)of Dlvislon 3 of the '
. Business end Pmfeesbne Cotle)or that he Is exempt therefrom and the basis for the alleged ASPHALT SHINGLES ]
exemptlon.Any violation of Sealon 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more then five hundred dollars($500),): -
❑I,as owner of the property,or my employees with wages as their sole compensatlan,win do _ WOOD SHAKES ❑
the work,ark the structure Is not Intended or offered tar Bala(Sec.7(A4,Business and Pmbr-
alons Code:The Contractor's License Law does not appy to an owner of property who builds or WOOD SHINGLES ❑
improves thereon,ark who does such work himself or through his own employees,provided that
such Improvements are not Intended or offered Or eels.If,however,the building or Improvement
Is sod within one year of completion,ft owner-bulider will have the burden of proving Met he cud OTHER (SPECIFY) ❑
not build or Improve for Purpose of rale.).
❑1,as owner of the property,am exclusively contracting with licensed connectors to construct
the project(Sec.7044,Busineas and Professbna Code:The Contrmar's License Law doss not PROVIDE I.C.B.O. REPORT NO,
eppfy to an owner of property who builds or Improves thereon,and who contracts for Such projects
war a contreaorle)ticer aetl pursuant to tiro Contractor's License Lew. PROVIDE MFGR.INSTALLATION SPECS.
C]I am exempt under Sec. ,B a P.C.for this reason
Owner Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of parluty ona of the following declaration:
❑I have and will maintain a of the ab of ConservM wit-insure for Worlsof the we Orwhieetlhis
as mit is Is fair by Becton 3]00 OI the Labor Code,for Me perlormar,ce of the work Or which this
permit Is Lve sir ci $ei
It
haveode will mefnleln Worker's Ca a work
which Insurance,as required by d.My Workers rs
Co 4to!%i
bon Code,for the peArier nd; of Policy
wad r a width U4n permit Is lesuetl.My Workar'e
Companselbn Insurance carrier end Paltry number ere:
GamierenyNo. W989171591 PERMIT AUTHORIZATION A E
CERTIFICATE OP EXEMPTION FROM WORKERS
COMPENSATION INSURANCE
(Thin lactim meed not be completed If the permit Is far one huntlred dollars(E100)100)or lees.)
I certify that In the performance of the=br which permit b Issued,I shall mu empty
any person In a manner so as to became act t orke mpensabon Laws of Call- All roofs shall be inspected prior to any roofing material being
fornla. installed. If a roof is installed without first obtaining an
Dara G April lcem inspection,I agree to remove all new materials for inspection.
E TO AP CANT: ll,after making MIB CertM a of Exemption,you should become A hcant understands and will toss I with all non dint
subject o the Workers'Compensation proNeicns of the Labor Code,you meet forthwith comply pp p Y p
with such provislonr or this permit shelf be deemed revoked. - source regulations.
I certly that I have read this application and State that the above InbrmatOn U correct.I agree
to herebycomply with all dry and county of this cae az enter upon
ths,albog nrullding cOro perry f entl All r erlDr}fj t�class Or better.
herebyauthoritiespurip lze representatives of thin Gty to enter upon iM ebovo-mentlonatl pmporry far In-
operation agreesea.
(We)agree is rerl a bdamnw and keep harmless the City ai Cupertino t sand C a sifter Ilebllltiee,
of the ra costs tris permit ee which may In arty way accrue against aeltl City n mneequertcav
of the grassing of this permit. ATU 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 ACCESS TO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY.