01080027 CITY OF CUPERTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD PT # H ALL SEASONS ROOFING SERV CES01080027
OWNER'S NAME: APPLICATION SUB DATE
AVERY CONSTRUCTION 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO,
4089724455
VM O O ARCHITEC rENGINEER: BUILDING PERMIT INFO
m w o BLDG ELECT PLUMB MECH
h<�
Z;J i LICENSED CONTRACTOR'S DECLARATION Job Description
Oz on 1 hereby affirm in.,1 an,licensed under provisions of Chapter9(commencing
r,
with Section 7000)of Division 3 of the Business end Professions Code.and my license TEAR-OFF, TORCH DOWN
a y is in full force ad effect pp p -f lq0 /
O ?/z a License Class C^J I Lis.p s >Y 7
seta a O Date S DELLA
w 3 u gRChull bo ve DECLARATION
an
1 understand my plans sial(he useJ as public records
p O Licensed Professional
n a OWNER-BUILDER DECLARATION
1 hereby affirm that I am exempt foam the Contractor's License Law for the
following reason.(Section 7031.5.Businessand Professions Code:Any city or county' -
❑ which requites a permit to construct,alrer,iur, ova demolish,or or,,any suunurc $3000
63_..,prior to its issuance,also requires the applicant for such Permit o file a signed statement - - -- -
that heislicensed parmant10the provisions ofthe Contractor sLicense Law(Chapter 9 t or eayv, Valuation
(commencing with Section 7")of Division 3 of the Business and Professions Code) 32bu 0 � � _
or that he is exempt therefrom and the basis for the alleged exemption.Any violation -
ofSection 7031.5 by any applicarq for a permit subjects the applicant to a civil penalty
.nrnet mom than five hundred dollars(ss00). 305APN�i - Occupancy Type
❑I.as owncr of the propeny,o my employees with..,as as theirede compensation.
-willdoNed Pro wtl the ods:T e C not Contractor's
intended Li orae Low for sale(gee:an an 307
6 01 - ROOF TEAS ejI#Inspections'
Business and Professions Code:The Com clism s License law does not apply m olf q p
owner of property em Wilds or improves at such andimprovements
who ems such work himself
oreFed for
sale If.
emeveF,t pmnded that impmtis sol arPnw intended or . 602 -.-ROOF.-.PLYWOOD NAIL-....
oRhed rdr tale.IL howevice the Willing or improvement Prot is sold within on year or
oimplction.Ne owncr-huiloler will have the Widen of proving chat he did nw Wild or 603 - ROOF BATTENS '
improve for paryoxe mfmle.y. 604 - ROOF I_ N-PROGRESS_
❑1,as owner of the property,am exclusively contracting with licensed contractors so
oonmct the project(Sec.7644,Business and Professions Code:)The Comracmr's t -
- Uceme Law does not apply to an owner of property who builds or improves thereon,
._and who.contracts for such projects with a conuacoads)IicrosM pursuant to the
Cmuracmh License law.
❑I am exempt under Sed - ',B&P C for his.,on �a rri�p� /^�s IpI IIsm�s
Ir O B V!'�x1 Loa L�FO)
Owner 'Dom
WORKER'S COhIPENSATION DECLARATION DECI 'I
I hereby alarm Linder penalty of perjury one of the following declaration. CII + + 2001
❑ 1 have and will mainwln a'Cenificam of Consent to self-in una for Worker's
Compensation, as,provided for by Section 37W of the Labor Code, for the BUILDING
performance of the work for which this permit is issued.
❑1 have and will national n Worker's Compensation Insurance,as required by Section
= e 3700 of the Labor Cole,for the performance of the work for which this permit is
issued.M'tA'*ars Cmgpenmtkm Inure carrier and Polity dgTbararc: _, __ _-_- -_ _ ... ... .
r ... .+.. -..... ...... - _
Carrico (' x h'" Policy No.:W G V 10 7 I7 v, T, r% _ fli"
CERTIFICATION OF EXEMPTION FROM.WORKERS' '
COMPENSATION INSURANCE
(This section neW not be completed if rhe permit is for one hundred dollars
(5100)or less.)
I stilly that in the performance mf the work for which this permit is issued,1 -
rshall'na employ any person in any m Liner so as at became subject to the Workers "
Compensation Laws of California.Date
.Applicant
'NOTICE TO APP the Worker's
aftCo pensati this Ceninsof of Exemption.yuoumuld
st '
Q Obecome subject tothe such pr Compensation provisionsofthe Lahr Cale,you must
forthwith comply with such provisions or this Permit W deemed revoked
' t i, CONSTRUCTION LENDING AGENCY t
1 hereby affirm (om
that them is o construction lending agency for the permnce
W.,'�y of th' workf hch this annil' issued(Sec,3N7,Civ,Cl
�.❑ - Lenders Name .- ..t_ ..
z Lenei,,Addiccs'
I"Li Iy[td l have Lad[,is;,I itilian said rude thsa the an.,<in mrm:u'mn is
ks',F correct.I agree to comply with all city and county ordinances and state laws relating
=U to building construction,and hereby authorize representatives ofthis city to enter upon
W the above-mentioned propcny for inspection purposes. ..
` Pit (We)agree m save.indemnify and keep harmless the City of Cupertino all
fin liabilities,judgmmty.costs and expenses which may in any way accrue against said O—
U .Zn City in consequence of the gmming of this permit. /Vyl
APPLICANT UNDERSTANDSA,NIYWILL COMPLY WITH ALL NON-POINT
- _ -
SOURCE REGULATIONS. Issued by: Date
Si mummnfA,,1i.evcnmmrm .. Date Re-roofs
-_ HA2 AR MATERIALS DISCLOSURE
' wlitheappr<nmtmr a Willingmcupantsloemrhmalleha,.,rdmustruerul Type of Roof- - - -- .. .-� .•. --- --- -- — . -- -_-.
- as dermad by the Cupeninn 1 icipel cote.Chapter 9.12,arta fact Health and safety - T:
Code.Section a,3321ay9 ... .t .. .
ova,' ❑No.. ' All roofs shall be.inspected.prior to any roofing material being installed.-, ..__
. ' •' 'Will the applicant orfuture building mcupantuse equipment'ore<viceswhich If a roof is installed without first obtaining an inspection,'I agree to remove
m -
emit hardous air contaminants as defined by the Bay Area Air Quality Management
District all new materials for inspection. Applicant understands and will.comply with
-,0non
Yes - .bNp .: all -point source regulations. - ,
1 have lead the hazardous materials requiretmnte under Chapter 6.95 of the
California Health&Safety Cade.Sections 25505,25533 and 25534.1 understand that
ifthe building does noicantently have a meant.that it is my responsibility to notifytbe - - - - - -
occupcut of the requirements hlch most M met prior m issuance of o Certificate of
,. ." Occupancy. .
�,_ Signature of Applicant ._ _. - . . - Date
Uwner or authorized i ` Data All roof coverings to be Class"B" or better
.,,--.... . OFFICE-- . .... .. . .. -. _. . .. . . .