R-6437 • 4
, r
PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 6437 .
REROOF PERMIT INSPECTION DIVISION - PERMIT EXPIRATION
v (408)777-3228PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 180 DAYS OF PERMIT ISSUANCE OR
1W DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11106-11136 Flowering Pear Dr.
.
Cupertino, CA RESIDENTIAL X COMMERCIAL OTHER
OWNER'S COuntrywood Homeowners Assoc.. HAZARDOUS FIRE AREA
c/o Communit Management Services YES ❑ nyas-I understand final a ClassA
NAME Y $ rod assembly is required.
NO ❑ Initial I.C.B.O.Y
ADDRESS
727 University Ave. , Los Gatos, CA 95030 EXISTING ROOF COVERING
PHONE _ NUMBER OF EXISTING COVERINGS 1 (Otte) each
CONTRACTOR'S '
Davey Roofing, Inc. TO BE REMOVED 1 TO BE RETAINED 0
NAME—
Davey
CIYADDRESS IXPEOFROOFCOVERING
22390'Thunderbird Pl. , Hayward, CA 94545
EXISTING
PHONE 510-293-9300 BUILT--UP ROOF
LICENSE
NUMBER - - ASPHALT SHINGLES ❑
UCENSED CONTRACTORS DECLARATION
I hereby affirm that I am licensed under provisions of Chapter B(commencing with Sefton WOOD SHAKES f]
71 of Division 3 of me Business and Professions Code,and my license Is In full force and
affect.
C39 700710
WOOD SHINGLES ❑
I-cense Class Lc.Number
Date Contractor Davey Roofing, Tnr- OTHER(SPECIFY) ❑
OWNER-BUILDER DECLARATION PROPOSED
hereby affirm that em exempt from me Contractors Ucense Law for the following reason.
(Sec.7031.5,Business and Professions Cade:'Any on,or county which raqulms a parrs 0
construct,alter,Improve,councilor,or repair any structure,prior to is issuerrce.also requiresthe BUILT-UP ROOF
applicant for such porhJt to file a signed statement that he Is licensed pursuant to the provlsl
of the Contractors License Law(Chapter B(commencing with Secdon 7000)of Dlvisfon 3 0l t
Business and Prolesslons Code)or that he is exempt therefrom and the Wsle tar me elle d ASPHALT SHINGLES ]
exemption.Any vlolatbn of Section 7031.5 by any applicant for a permit subjeae the eppllc
a cMl penally of not more than We hundred cohere(§500).):
[:j1,es owner of the property,or my employees with wages as their sole compensation,will do D HAKES ❑
the work;and the structure Is not intended or offered for sale(Sec.7044,Business and Profes-
sions Code: The Cont rectors Ucanae Law does not apply to w owner of property who builds 0r �yV SHINGLES
Improves thereon,and who does such work himself or through his own employees,provided that El
• such Improvements are not Intended or offered for rale.If,however,the Wilding or Improvement
Is sold within one year of completion,the owner-Wllder will neve me burden of bewng met he ad OTHER(SPECIFY) ❑
not build or Improve for purpose of aab.).
❑1,as owner of the property,em exceelvely conlrectlrrp with licensed contractors to construct
the projectSal 7041,Buslrtess and Professions Cade:The Convectors Ucona,Law does not PROVIDE I.C.B.O. REPORT NO.
apply to an owner of property who Wide or Improves thereon,enc who contracts for such prolecb
with a commutor(a)licensed pursuant to me Contractor's License Law.
❑1 em exempt under Sec. ,B a P.C.for this reason PROVIDE MFGR. INSTALLATION SPECS.
Owner - ' Date APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm uMer penally of perjury we of the fdbwkq declaration:
cllon d
[:]I have and sofa mountain a Certificate of Consent to sell.lnsure for Workers Compensation.
as provided for by Se37W of the Labor Code,for the performance of the work for which fhb l/fitng
pare It b Issued.
v]I hese and will maintain Workers Canpell
enson Iruxurhs ,as required by Section 3700 of / `Sei �RR/0
th Labor Code,for me performance ol the work for which this Permit is Issued.My Workers u
compensation Insurance carder and Policy number are: L _ s Z• T
Carder California Componsatior icy No.W985171591 PERMIT AUTHORIZATION D T
CERTIFICATE OF EXEMPTION FROM MRKERS'
COMPENSATION INSURANCE N.C.0 O
(Thus section need not be completed it the Went is for one hundred dollars(§100)or lees.)m
I certify,that In the performablehell ro
of me work for which thin parent Is baued,I shell empty
any person In eery mann eo ee to becoe eu t to Wane Cempensatbn Lewy el call- All roofs shall be inspected prior to any roofing mate hal being
fornia. installed. If a roof is installed without first obtaining an
Data �' Applicant inspection,I agree to remove all new materials for inspection.
Nor E TO (CANT: If,after making ml Cedlficata of Exemption,you should become - Applicant understands and will subject to fha Workers'Compensation provisions of me Labor Code,you must forthwith campy pP comply P Y with all non point
with such provisions or this permit ahalpbe deemed revoked. Source regulations.
I cerety that I have reed role application and state met the above Information is conecc I agree
to comply Mm all city and county ordinances and state laws relating to Whiting consvucllon,end All roof edit SS or better.
hereby authorize representatives of Ins city to enter upon the abovamenboned property for In-
spection purposes. �L
(We)agree to save,Indenmfy and keep harmless the City of Cupertino apalnst liabilities,
judgments,create and expenses which may In any way accrue against Bald Cly In consequence N URE F APPLICANT ATE
of the of role permit.
PRE-INSPECTPECT ION: PLYWOOD: IN-PROGRESS:,
INSP. DATE INSP. DATE ' INSP. DATE '
TEAR OFF INSPECTION: BATTENS: FINAL: .
INSP. DATE INS P. DATE INSP. DATE
NOTE: OSHA APPROVED ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY .`