01080021 YI
CI non°FiNc oPvERTINO CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD PT ALL SEASONS ROOFING SERV CES01080021
OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/03/2001
PHONE: SANITARY NO. CONTROL N0.
� 4089724455
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
ad
BLDG ELECT PLUMB MECH
LJ LJ IJ GI
tF-y i LICENSED CONTRACTOR'S DECLARATION
>.O I hereby affirm that 1 am licensed under provisions of Chapter commencing Job Description
Fy_w with Section 7W0)of Division 5 of the Bmmessa.d Professions Code,end my license REROOR.
as,yf force and f9g T/0 & ADD OSB & COMP.
c s a Lii ens"Clads C 7 Lic.g
O u U Date -b��a /— Contractor_ __
0A�HI'I ECTSDECLARATI
C- S I undcrstarM my plans shall he used as public record
w C O Licensed Professional
c o OWNER-BUILDER DECLA ION
1 hereby affirm that I am exempt from the C racmr's License law for the
Fa following mason.(Section 7031.5.Business and Professions Code:Any city or county
cF O which requires a permit to construct,alter.improve,demolish,or repir any structure
ou 3='0 -° !'' al req tM1 ppI t f h pe n tt fl g dstatement.
t r -d l t t to iuu, ,r it nfi,Cmuuour,L .-I (C"I t r9Sq:J"t Floor Area
p ntngwah5 tgn7W0)of Div 1 ria. the Burs,an
nd Profession.Code) �'„$'e A ,i;r _ +• c,v.r s, _,
or Nat he is exempt therefrom and the basis for the alleged exemption.Any violaion
of Section 703 1-5 by any applicant for a permit subjects the applicant to a civil Penalty
of not more than five hundred dollars(SSW). A PW umber Occupancy Type
❑I,as owner oRhe progeny,or my employees with wages as N<ir sole compensation,
will do the work,and the structure is not intended or offered for sale(Sat.7(1
Busitrcss and Professions Code:The Contractor's License Law does not apply to an 307 - INSULAT1RoNjired Inspections
owner of property Who build,m improves there..,and who does such work himself
or through his own" pl y e provided' th t h improvements arc t intended or 601 .. _ROOF. TEAR OFF _I_ _
,.or
forsolc If.h - rheb kig p imem old-withinone year of - 602 — ROOF PLYWOOD NAIL
'completion the owner builder will have the burden of pmvmg thin he did not build or
improve for propose ofsale.). 603 — ROOF BATTENS
°Las owner ofthe Property,lam exclusively ProfeingwCodh:).The Contractor's
604 — ROOF IN—PROGRESS "
a.mmctmnd who c a project(See]611 Business and Professions ills or mgr ves theme's ��
C Law does not apply,oan owner of propertywho buildsorpmmuth1-ths, ALE r�
_ icenuors Lixem.fL such.Projects.with.a.comracmrts)licensed pursuant ns.the _.. .. LbL�D.
mnmrva,
L
Owner s pt under
Law. - -: -
- . ❑IamucmplundcrSee: - - s' ,B&PCf.nhisrtason DEC 1 � �� - ��� f
ost" 1 2001
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of,he following declmarimse: ��'��'��
❑ 1 have and will maintain a Cenificdm of Consent im self-inxure for Worker's
Compensation, as provided for by Section 37W or he-Labor Cade; for the
o
performance of Our work for which his permiI is issue,
°1 have and will maintain Workers Compenwiion Imuran s,'ui required by Section
37W of the Labor Code,for the performance of the work for which this pemtit is
issued.Mya mbar',ComTerms ai Insumncecartier onit Policy tuber art:'
//ya C/ 9y
Carver. //CATI •Polity IO RO� C. �•
li
CATION INSURANCE -
' - _ COMPENSATION INSURANCP. „ _ _..... . .-.-.... _ ....._.-...... _........ ._-_-....._.._. .... ___ __.,
This section need not me completed if the permit is for one hundred dollar "- "u'I " •`(SIM)or less.)
1 cell fy tha er in f m ce finework,for ram, the. nil a issued,1
shall not employ any person m any man so ro bea.rmm subject io the Workers'
Compensation laws of California.Orae'
Applicant
•NOTICE
mesubj APPLhe WNr:r aCom,mout raskimaae of Laturioo,y°ushould
became subject comp y the surkcr's aimar,or bis probisishall the LaMv Cade,you must
Q O forty'I comply with such provisions- this pemuuM1all be tleemmmd revoke.
.f Ne work for
CONSTRUCTION a - -'
E r _- %ucoNLENDING AGENCY - - - -
W � i rte n Ira that m ep, , mriamg agency for the perr.rman"e
permit is issued ISed:?09].Clv.CJ
C!Z under s Name
.7 1Z - -
Iindcr'i Address; , .. �. .. ' .. � ,
,1 certify thin 1 have read this ap,afa.ticm and atom that the above inromtaion is
Fs coriecu 1 agree to Comply with all city and county ordinances and state laws bela,ing
I) to Wilding construction,and hereby aa,honie mpresen,x,ives ofthis city to enter upon
>,:(p) the above-mentioned property for,inspection purposes., .
[r'0. (We).gom I( adetnifyabkep harmless rh Cty fCpenria'a,inst
Vi
liabilities.judgmentu.costs and expenses hich may.in any way accrue against said
Q Z Cay n rose wence ex efX.' ng of th pc n
APPLICANT uIUDr ST ND WILL COMPLY WITH ALL NON-POINT
SOURCE 1 Issued by: Date
REGUL ' t•'
SlgnammofAppl t - - Re-roofs
ndCan a '.Dam
rON.
OUS'MATERIALSDISCLOSURE WII theuture Buildingoocupanr store of handle hazardous material Type of Roofas defred by rhMuniepul Code,Chapter 9.12,and the Health and SafetyCode,Section2 ..❑Yesr.�� _All roofs shall-be-inspected prior_[o any-roofing.material.being installed.___Will'hcfurorebuildingoccupmuseequipmentmdeviceswhich If a roof is installed'without first obtaining an inspection;I'dgree to remove
emit hniurd.usans as defined by the Bay Area Air Quality Management
Disma] all new materials for inspection. Applicant understands and will comply with
°Yr °No all non-point source regulations.
" I hove read the hazardousmcurmIx requiremenu under Chapter 6.95 of the
California Health&Safety Code.Sections25505,2551?and 25534.l understand that
if the building does not currently have a renamahai it is mpo
y resnsibility m imify the
occupant of the rcquimmene hich as,be met mord issuance of a Certificate of
Occupimcy.
Owner or aothomeda _ Dam
e PP .. . " Date
_ Signature o .A licant _ Dat
.. „" All roof coverings to be Class B or better '
• OFFICE - --