01080026 CITY OF CUPERTINO
BUILDING DIVISIONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD PT # K ALL SEASONS ROOFING SERV CES01080026
l OWNER'S NAME: APPLICATION SUB DATE
AVERY CONSTRUCTION 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
4089724455
w O O ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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m Z LICENSED CONTRACTOR'S DECLARATION Job Description
F lhereby
on7000fiofDiviion3rm that I am oftheBunder
ssandPronsofChapter sCode.andmmencing
se RE—ROOFr APARTMENT COMPLEX
0 [_m wiN Section]11007 of Division3 of rhe Business and Professions Cade.andm license
a F< isinfullfares.de t�99 4M-71
E z 6 Licenu Class eo Lic.# II''�L 7�
a F Date Camra m
ARCHITECT'S DECLARATION
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O g 1 understand my plans shall be used as public records
� f
Licensed Professional
OWNER-BUILDER DECLARATION
wy I hereby affirm that am1. exempt from the Cessions o License Law for the
F Z a following cures.permit
1 ] S.Business and Professions Code:Any city or county' $3000
I d o which r q 'rv.a pe m i t construct,a¢r pre d I h o rep. y wcwre
i 3= poor to t ounce,also rc to rest appli ant 1 r h perm t t f c gned halike -
ththe `lan{eel pu u Ito the pro s :of the C Contractor L' W IChapter9
(enmmenemgwith Set n71g0)orDi 'S n3ofthe Bus ssagd Profs si ns Code) r : .( + ValnatlOn
21909Qgg . 0
3
or that he is exempt therefrom and the basis for the alleged exemption.Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant in a civil penalty
of no, amtban five hundred dollars(5500,. 305APN ji i Occupancy Type
❑l,as owner of the property,or my employees with wages as their sole compensation. _
'will do the ask,and the atrvmure is not intended or'offered'far able(Sec.7044,'
Business and Professions Cale:The Contractors License Law does not apply to an 601 — ROOF TEA]Kegp}p'Inspections
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided that such improvements are not intender or - .._ - 6 _.,02.._-_.ROOF PLYWOOD..NAIL _ .._. _..
Wand for sale.If,however.the huild-ng or improvements sold within one year of 603 — ROOF BATTENS
completion,the own b Ider will have the burden of proving that he did not build or
mprove for purpose of sale.l. 604 — ROOF IN—PROGRESS
_._. .... . .. . ..... .. ._ . . ._ _ _ ..... .
0-1,act owner of the property,,1 xdi rvely d Praccing with ImensW acontractionCmura m
conswn the does
ram
(5,,.7014,Business and property
who b Cade.The Contraanr's
License Law does not apply. an owner of property who builds m improves thereon,
oral who contracts W s ch Drslectz. 'th. contracmrts7 licensed pursuant to N
Gnmraetnr a License❑I on exempt smelt sec' ,B&PCforthis rc.eonUNALE D
O ser .. Data
WORKER'S COMPENSATION DECLARATION DEC9L00.1
_ I hereby affirm under penally of pe,jory,one of the following deadinu ns: lh9 I
❑ 1 helve and'will maintain'aCertificme of Consent'to self insure for Worker's BUILDING_ - Compensation, as00,provided far by Section 37of the labor Code, for the
'pertmmance m the work far which this perm's is issued.
❑I have und'will maintain Worker',C p t hourrom.as res red by Section
3]00 f tM1RC
COJ f th pert f tM1 k f 6 h this perm t is
E.
MyC pe t I. c e d P l ry be arc:
................
Cir .r t rTIFICATION OF FXEbIPT10N FROM WOR RSl.T ' i•
,. COMPENSATION INSURANCE , .: .� ., .. ...._ __. . ._a.-_ .. _. ._.___ _...._ __... ._.,. .. .,.
... _
m l'k a t tion need'not tieoomplctcil if the permit is for one hundred dollars
(51001 or less)
I I n'fyahat Mperfornuns fth'e ark for whch'[h.Pe not isouedl
shall' i ploy'.y pe y matrucer so as m became subject to the Worked
Compensation Laws of California Date -
.Applicant. _. .. ._ ._ ...._._ _._ ...._ ... . ..... .. . .. ... .... .. - i .___..
NOTICE TO APPLICANT If,after making this Certificate of Exemption.you should
C Obecome'stmoct t0 the Worker's Compensation provisions of the Libor Code,you must
forthwith comply with such provisions or this permit shall be deemed rooked,
Fr . . ... . . .. .... ._ .. .- .. .. ... .....
CONSTRUCTION LENDING AGENCY _
�i�Fw f w hereby
k for which this pc rel is issued(Sir.3097.C g mi
is a Y Tot the performance
the - -
L._ -Lcmi Nauru
-`
J-� Ic tlYth: 11 d ihly aVll i inJ aamtl nl b eiiiiir m n s
- til Fycii I agree to cmmply with all city and county onfireances and state laws rel ting'.
0. to building coiisnuction,and hereby authorize representatives of this city to enter upon',
.W
the b mid formerly to,inspection pur o
(We)ag`et demmify andkeep ha less the City ofCupe,rpm,against
on liabilities.judget t and expenses h h yinan, y carm,against eaiA l �,
U � Cty g c Tgr ng of ih c
APPLICANT UNDERSTA TA r ❑WILL COMPLY WITH ALL NONPONT Issuedb Date
SOU CE REGULATIO Y'
Sigi wre orAppLr Mcnmm r •; Date
Re-roofs
HAZA US MATERIALS DISCLOSURE
W 11[Ae applicant o tore build g c p t stere or hrndk nvnrdou serial ... .Type of Roof --
as defined by the CuNnii nicipal Code,Chapter 9,12,and the Health end Safety
Code,rsmile*355321a1 ti .be inspected-prior to�any�roofing material being
'ori "� iplyn -All roofs shall installed.,
will had applicant or,future bolding occ p nt us. q p t devie s wbah If a roof is installed without first obtaining an inspection j-agree to remove
humorous caritau contaminants as defnd by the Boy Aea Air Quality Maagement
•.
District? all new materials for inspection. Applicant understands and.will comply with:_
'[3y" - o No F, all non-point source regulations.,
I havead the hazartlous materials requirement,under Chapter 6.95 of he
California Health&Safety Cndr.Sections 25505,25533 and 25534.I undecaand[id'
;relaflue buiofthe es not Curr is which ave a
chair,that it pt'i,,runim off tonotm the , -
Occupant of the regri entente which muni he met prior tb iksuance of a Cenificme of
Occupancy Signature_of Alicant Date
_p
P.
w r.raatn <I g ntDote All roof coverings to be Class"B" or better' "
.. :.. .. _ .... OFFICE . . . .. .. ... _.... .. —-_