01080029.� CITY ILLDING DIVISSION O CONTRACTOR INFORMATION:
.. PERMIT
\, BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD PT # J ALL SEASONS ROOFING SERV CES01080029
OWNER'S NAME: APPLICATION SUB DATE
AVERY CONSTRUCTION 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO,
4089724455
9 O Yp ARCHITECUENGINEER: BUILDING PERMIT INFO
kL"m F BLDG ELECT PLUMB MECH
�Z<n LJ 1_..-I L_j I-1
Z 8 vm=i_ LICENSED CONTRACTOR'S DECLARATION Job Description
O Z F I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing
F:—J with Section 7000)nf Division 3 of the Rosiness and Professions Code,indihy license RE—ROOF, APARTMENT COMPLEX
<m 2< in lull forte and cff
m eco i 6 Limnsa Class —3 9 Lic.x 9D�I�
.3 a Dale Contra nor
ARCHITECT'S DECLARATION
g1 understand my plana shall be used as public records
aO O Licensed Professional
Oat I am BUILDER DECLARATION
1 hereby affirm m, I am exempt from the Common's License low for the
following mason.(Section cursor t.alter. and ver demolish,
e io li Code:Any city or county^ $3000
F x p which mq.;ms a permit m cnnswn,pplic improve,demolish,m repair any structure
A Be 22 -prion.its issuance,also requires the applicant for such Permit file a signed statement - --
thmheislimma pursuatn,oHe provisions mf,he Contractors License Law(Chapter9 �f, r a Valuation
fmmmc«ing with Slow.7000)of Divisinn 3.f the Business and Pmfessi°ns Code) ( 32b'0 0 �°.
.1'hat he is exempt therefrom and the basis for the alleged exemption.Any violation
of Si mlon 7031.5 by any applicant lot a permit rill ect,the applicant m a civil penalty
.of net more than fve hundred dollars($50% 305 APN�i�i Occupancy Type
°1,as owner of the property,or my employees with wages as their sole compensation.
will do 0c' Ismi and the ode:Tstructure rs not trended.r offered for sale rsec, toa n 6 01 - ROOF TEAM9t��'ft'Inspections
onscar as and erty Who b Code:The Con,mmoro ,and w Law d«s not apply m on
ow«rug profs ow Who builds or improves at such,and who d«s such work himself
or through his own however,t building or such improv meal.are not Intended or 602 — ROOF .PLYWOOD.. NAI L
offered for sale.It,however,,tie building or improvement ocmcmon sold within one year of
completion,the ow«rvhuilder will love Urc burden or proving thin he aid no,Budd or 603 — ROOF BATTENS
mproverorpurpaseofsale.). 604 — ROOF IN—PROGRESS
—.
°1,as owner of the piSm.7 an exclusively a c.mr«,ing with licensed contractors ractm r• ..
- _ .carom the project lave. to a Business and Professions Cadea The Contractor's
.^ ' Litems law does not apply m an owner with
apropertycomer who builds si improves in di.
and who contracts for wch,pr.jas.with a commeror(s).licenud pursuant m thr
Contractors a.o's's p,and Law.
-- ❑Tem exempt undtt Sec ,B&PCfor this
DEC 1 1 2001
Owner Date
WORKER'S COMPENSATION DECLARATION p1
I hereby art,.undo penalty of perjury one addle following declamtumrs BUILDING
° 1 have and will mm6lain a Certificate of Consent to self insum for Worker's
_
Cooperstown. as provided for by Section 37W of the "her Code, for the
Performance of the work fm which this permit is Issued,
O 1 have and will maintain Worker's Compensation Insurance,as required by Section
_ 37W of,he Labor Code,for the performance of be work for which this Permit is
issued My Workers Comproalion Insurance carrier and Policy number am' Y
. Cartier ( ,s�Fol'cy Nu:WI��WI�'}TO /�� ? .. '�• t .•
i.EIFIVICAIIUNOPEXEMnIONh OM WORKERS'y
_ .. . -. COMPENSATION INSURANCE
(This seminn ncaf w,be completed if the permit is for one hundrW dollom 1 _ .. )!L ., q�, .
(SIM)or less.) ,
1 comity that in,he pedolacnce of the work for which ibis permit is Issued.1 - i;,, }, .,fl;- --
shall not employ any person In any mountain so m,o become subject m the Workers'
Compcnation laws of Ci lifomia.Data
Applicant
:NOTICE TO APPLICANT':IL i fter nmking,his Cenilleme.f Exemption,you should
becomew subject the Workers Cmnpemm
mion pvsi.ns of he Labor Code,you mull
CQ forthwith comply with such provisions or this permit shall Is,deemed revoked.
F1� "" CONSTRUCTION LENDING AGENCY - - - - --
1 hereby affirm that,herr is a construction lending agency for the performance
-.. of the work for which this permit is issued(See.3097,Civ.C.)
j;QLender's Name. .._ .. . -
Lvulcr s Addre
V im^ Icenify❑u,lhnn read this applicmi.n and sou tha,hc abure infonmti
W i ton cotmcd:I.agree,o comply with all city and county ordommuc,and state In.,relining
0.:V rebuilding cons,mcti°n,and hereby authorize'representatives of thus city to enter upon
} Kl ,he above-mentioned property for inspection purposes.
^e. 0. (We) g... indemnify and keep hrmlesa the City ofCaperton against
Z? liabilities,1 dmo
irrov,costsd cv,mors hiih may in any a,,accrue hgai t said
S.1,Z C'ty c yYND slth g i g.d,H9ps t T
APPI(CANT UNDER5TAM1D5 AND ILL COMPLY WITH ALL NON-POINT QQ C. �� ,,,,_ __ Date
. SOURCE REGULATIONS � Issued by: /J
Signumrc of ApplicanVCnnwcm - Dam Re-roofs
HAlARDO MATERIALS DISCLOSURE
ns dcOnWll,he applicant or Biom Wilding.mupm,sort N
or handIc haraoumaterial aterial Type of Roof
tl the Cupertino Municipal CMB,Chapter 9.13,and,he Health and Safety
cede.Section u532thc
0YP9 b"° All roofs shall-be ins pected.prior.to any roofing.material,being installed._.. -
.Will the applicant ortoprebuilding occupant useegwpmen,mQevi«swhich If a roof is installed without first obtaining an inspection,'I•agree'to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Managemem
•i
Dorset? all new materials for inspection. Applicant understands and will comply with
°N all non-point source regulations.
1 have read the haaN°us materials requirements under Chapter fi 95 of the l
California Health&Safety Code.Sections 25505.25533 and 35534.1 understand,hat� _
,if,he Wilding does nod curuntly have.to anUhat it is my responsibility to nmify,he
occupant.f the requlrcmems which must be ntet prior to issuance of a CemAl,stc or
Occupancy.
- Signature of Applicant Date
Own rr or awn.r a agent mare All roof coverings to be Class`B" or better'
OFFICE