01080028 ITY OF
C
BUILDING DIIV�IISSIIONNOPERIVLIT CONTRACTOR INFORMATION:
• BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD BLD 9 ALL SEASONS ROOFING SERV CES01080028
OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
4089724455
O O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LI
�?y
a se
sea LICENSED CONTRACTOR'S DECLARATION Job DBSCrIpIIOn
O z— 1 hereby attirm that 1 am licensed under provisions of Chiprcr 9(commencing
F,at withSeeam.7000)ofDivision3oflheBusicessandProfessionsCode,and mylicense TEAR OFF OSB COMPOSITION
z m I is In full force and effect ff �/-�09/ f r
c.z z¢ License Class —J� Lic.N
w 3 any Dale Contractor T
E O ARCHITECT'S DECLARATION
I=— 1 understand my plans shall be used as public records
IE ch
da i p C Licensed Professional
se
OWNER-BUILDER DECLARATION
uX+
In, I hereby affirm that 1 am exempt from the Contractor's License Law for the '
t_-Z a following reason.lceciion omr,tr Business and Professions Code:Any city ,county" $20000
Exp which requires a permit m construct,1pl c improve,Demolish,or ream,any svucmre
c.3'� Pnonoi¢censed puaarequiresmeapplicsofthe ontch p oes Licerw Law(Ch mem - -- --- -
maheisllcenseDaursmnnottrap f Division me the Busters License Lawons Coe) ,�Cyy, F rep[Qa. , VaIUBDOn
(c that he is ewith Section 7000)of the basis 3r t the Business and Professions Cadet _ 3 L O O O�4jO,l V <S..'• s;
or that he is exempt Iherefram tori the basis far the alleged exemption.Any violation '
of Seclinn 7031.5 by uny npplic..far a permit sobjects the appl icam m e civil penalty
.ofart moremanfive hundred teBars(s50 ), 305APN i 1� Occupancy Type
13 1,as owner of the property,or my employees with wages as their sole compensation, - _
will the work,and the odeTstructure is narimended'a aBLaw doe bale epee.Toa. 601 - ROOF TEAP&egbFfl'Inspections
•ower of am ProfessionsCode The Commcmr s. ad w few does not apply to an
o f p party e l ilex or'mident t thereon,and who rices such work himself
o en through his own employees.provident that such improvements within
not intended
year or _ _ 6 O Z ._. _ROOF PLYWOOD_.NAIL.
'completion,
f I If K e l Ih building-or vthe
mpmvemeat n sold he din ane year of 603 - ROOF BATTENS '
' the owner builJer will have the burden of proving that he did not buil)or
mprove formaTase Uf sale.). 604 - ROOF IN-PROGRESS
❑L as owner of theexclusively.. .. _ .._... .._._.. _ __ ....._._..._.. .. .. . .._.... ._ ._. .... __ _ .....___
progeny,am Business
d Profess with de:)T s Cmitaon m
_
construct the does
IapplSee. to a Business arta Professors code:)The etame's t:..'.
License Law does not apply m mj owner h progeny who builds or sepa,.improves thereon.
!. inal Cmaraco commens for.such Protects with.a contmemns)licensed Pursmm ..,he .. . ... ..__... _ .. _._ . .._ __.
111 a.exempt
License Law.
= ❑Iain exempt under plc. •,B&PCfor this reason rr�� r�� n p r� 'tsps
Owner .. Dine . . Ir-0 B V 1A LSmS
- WORKER'S COMPENSATION DECLARATION
" I hereby affirm under Penalty of perjury one of the following duelaralions: DEC
fS 1 11 2001 L 0 01
Eli have and will maintain a certificate or Convent to self-inwrc for Worker's C l�
Compensation, as provided for by Section 3700 of the Labor Cade. for the BUILDING
�
"performance of the work for which this pemat is issued. Ip U I L D I iVG
❑I have and will maintain Worker's Compensation Insurance,as required by Section
37M of the Labor Code,for the performance of the work for which this permit is
MY WarkelsCmmpc ns nc rterand
Cartier t^' 4 " - `" policy N.
CER IFICATION OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section need not IN completad If the permitis for one hundred dollars `
(51 W)or less.)
I certify Iha[in the pct 'e of r k t which u i pe rt e Issued,1
`ahall'dm ation L uny person n any Data as to become subject m me Workers `
r so "
C pe.'tion Laws fC'If nia.Dat Applica
NOITCnt - .. ._. .. _._.. .. _. _. .._. .._.. . ._ _ _-
NOTICETOAPPLICANT:If,ager making this Ceniticom ofEmmption;youshould ` '••• '' t"
be comply
the Wok Compen t sp 'pionsli edemed Curie.you must
i Q O
forthwith comply w Ih h provisions the permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY
a"> "" Ihereby'ofum that there is a construction lending agency for the performance -
'ofm work h hm issued(Se 3097.Civ C)
C LQ Ic ears Name' " I _ _ ...:.,.... . ..... .. ...__.. .,._ _. ..____ _ . .... .. .. ._._. _ ._ _ _ . ..
'y p 1 6
D'Z ., —
`� 1 ccnify mot I hive reud this npplivation and ewte that the above Inlonnatiml Is
ks>[� tract.I agree to comply with all city and county ordinances and state laws relating
:m
0 building em stmclibn,and hereby amhorize repo senalive6 of this city to enter than
the above-mentlaned property for inspection purposes.
Ea2G
(We)ag1sldemnifya dkeep W I -s the City of Cupertino against
t4 I b Iitics,judgments, 1-and expenses which y in any y hue age nal said !/ 'r•��
V;y cain of the gulling of thisOe t'
APPLICANT UNDEkSTANDS'AND\ COMPLY WITH ALL NON-POINT IDate
SSued b l
SOURCE REGULATIONS , . Y
S gn 1 rc of ApplicanVCon[mcmr Dale , Re-roofs A7--�G•1
ns d f nee b me532(a t o f f re hui g N i t re or hamlle hu>ar /
C� goys 5 HAZARDOUSM "RIALS DISCLOSURE
.. wnmea Health
Type _ _.. ,
tion
y C2m) M n c p: Od Chapter 9.12 d the Heolm and Safely �. \ _
❑b, .I,;` 1.. , ..
t . t All roofs shall be inspected prior to.any roofing material,being installed .__..
Will the applicant or.future building p t use equipment or devices which If a roof is installed without first obtaining anrinspectiou;I'agfee'td remove
air hazardous air contaminants as defired by the Bay Area Air Quality Man g ment
District? , ,. I I all new materials for,inspection. Applicant understands and will comply with
11 Ye` El No all non-point source regulations.
1 have read the hazardous materials requirements under Chaple 6.95 of the
California Health&Safely Cade.Sections 25505,25533 and 25534.1 uaderswnd mull -
"-nil . does art di m.muiirmy spoitymnthe
ccupor'ofthe req ....h Iwrich most be me[prior issuance of Certificate
Do pcy
-
Signature of Applicant .. Date
Owner m amlarizad ant .. , �- Date.: All roof coverings to be Class "B"or better.
....- _.-. -OFFICE - .. ..._ . . ._ _.. ..