R-6436 PERMIT R_
APPLICATION FOR CITY OF CUPERTINO NUMBER 643
6 .
INSPECTION DIVISION PERMIT EXPIRATION
REROOF PERMIT (408)777-3228 PERMIT EXPIRES IF WORK IS NOT STARTED
WITHIN 100 DAYS OF PERMIT ISSUANCE OR
' 100 DAYS FROM LAST CALLED INSPECTION.
BUILDING ADDRESS
11016-11044 Holly Tree Lane
Cupertino, CA - RESIDENTIAL X COMMERCIAL OTHER
OWNER'S Countrywood Homeowr ars 9ssocHAZARDOUS FIRE AREA
YES ❑ IF yes-I understand that a Class A
NAME C/O Community Management Services roof asserrolyisrequo-ea
NO ❑ Initial I.C.B.O.It
ADDRESS 727 Univeristy -Ave. . Los Cotos CA 95O 0 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 94545 TYPE OF ROOF COVERING
ClTvazlP 22390 Thunderbird Place, Hayward, CA
EXISTING
PHONE 510-293-9300 BUILT-UP ROOF
LICENSE
NUMBER 700710 ASPHALT SHINGLES ❑
LICENSED CONTRACTORS DECLARATION
I hereby afPom Chet I wh licensed under provlefone of Chapter B(mmmandng with Section WOOD SHAKES
7000)of Divlsion 3 of the Business end Professions Code,antl my license is In full force and
affUcaa C39 700710 WOOD SHINGLE /nom ❑ �I
Ucemea Class Uc.Number /�-=1�
Davey Roofing, c. OTHER(SPECI D ❑
Date Contractor
OWNER43UILDER DECLARATION PROPOSED APR 16 1999
I hereby affirm that I am exempt tram the Conaactors License Law for the blbmrg r
(Sec.7031.5,Business and Prolesefons Code: Any city a county which requires a permit
construct,alter,Improve,demolish,or repair any structure,pdor to Its Issuance,also requires the BUILT-UP ROOF
applicant for such permit to file a signed statement met he Is Hmnsetl pumuent m the provlslone B
of the Contractors Llcensa Lew(Chapter B(commencing with Section 7000)of Drots10a 3 of the - Y
. Business and Professions Code)or that he Is exempt therefrom and the basis for the alleged HALT SHIN
exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant to
a civil penalty of not more than five hundred dollars($500).):
C]1,as owner of the propend,or my employeeswIM wages as their sole compensation,will tlo WOOD SHAKES ❑
the work,and tl,a structure Is not Intended or offered for sale(Sac.7064,Business and Prof".
alone Code:The Contractors license Law does Trot apply to an owner of property who builds or WOOD SHINGLES
ov
Impres thereon,and who does such work himself or through his own employees,provided Mat ❑
such Improvements we not intended or offered for sale.If,lfi v r,the bulldIng or Improvement -
IesoMwithlnone year olcompbtbn,Ne owner-bulmerwlll have the burden ofprovingthat hedid OTHER(SPECIFY) Elnot build a Improve for purpose of sale.).
❑I,as owner of the property,em exdudvely,contracting with licensed convectors to construct
the protect(Sec,71 9 ,Business and Proleeefons Code:The Contractors uceme Law does not PROVIDE I.C.B.O.REPORT NO.
apply to an owner of property who builds cr Improvm thereon,and who contracts for such Project
wtm a conifimtor e)licensed pursuant to the Convectors Ucame law. PROVIDE MFGR.INSTALLATION SPECS.
01 am exempt under Sec. ,B&P.C.for We reason
Owner Data APPLICATION DATE VALUATION PERMIT FEE
WORKER'S COMPENSATION DECLARATION
I hereby affirm under perielly of perjury one of the fallowing declaration: �j
❑1 hese end Mill melntaln a Cenlflcate of Coneenl to self-insure for Workers Compensation, Building v
as prwided for by Secibn 3700 of the Labor Code,for the performance of the work for which this /
permit Is Issued. 9 (g(
ISI have and will maintain Worker's Compensation Insurance,as required by Section 3700 of / • Seismic
Me
Cnbar Code,for the performance of the work for whfoh this permit Is Issued,My Worker'
Compensation Insurance carrier and Pollcy number are: Total I
Carden California CompensatioLlayNo. W985171591 PERMIT AUTHORIZATION DATE
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE N.C43
(This section need nal be completed H the permit Is for one hundred dollars($100)or less.)
I certlfy that for the performance of the work for which this is Imum,I shell not employ
any person I an211CM�:
so as
to becortn eu m w r;Comperreation Lowe of can- All roofs shall be inspected prior to any roofing material Being
fornia. ' installed. If a roof is installed without first obtaining an
Date Applicant inspection,I agree to remove all new materials for inspection.
ICE TO If,after making thl ntlncate of Exemption,you should became Applicant understands and WIII comply with all non point
sus to Ore Worker'Compeneetlon pravlslons o1 the Labor Cade,you must brihwith comply ^fop P Y p
with such provisions or this permit ehe11 be deemed invoked. Source regulations.
I mrtlfy that I have read this application and state that the above informetfon is correct.I agree
to comply Mth all city end county ordinances and state laws relating to building conslrudion,end _ Ail roof erl s to be class"C'or better. p�'+
hereby authorize rapresentetives of MIs cry to enter upon the ebwamentlonad property for In specti
hereby
purposes.
(We)agree to save,Indemnify and keep harmless the City of Cupertino againstIlabllitlee,
judgments,mets end expenses which may In any way accrue against said City In consequence
of the granting of mLs permit. SIGN CUR OF 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 ACCESSTO ROOF SHALL BE PROVIDED FOR INSPECTION
OFFICE COPY