01080030 CITY
I BUILDING DIVISION
ERTNO
ryONPERMIT CONTRACTOR INFORMATION: "
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD BLD 10 ALL SEASONS ROOFING SERV CES01080030
\a OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/07/2001
:PHONE: SANITARY NO. CONTROL NO.
4089724455
z z ARCHITECTIENGINEER: BUILDING PERMIT INFO
O O BLDG ELECT PLUMB MECH
I. l CI
yah
IF- LICENSED CONTRACTOR'S DECLARATION
ZO Z y I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
P_Fm witnSerum.7000)of Division3n1the BuslnessandProfessor,Code.and myfianse TEAR OFF OSB COMPOSITION
a E is in full force and eff p z r _
z 8�a Lice se Class Y'-39 Lic.N S/D�
m a O y Date Commit.,
ARCHITECr'S DECLARATION
I understand my plan.shell be used as public records
I
6 n p 0 Licensed Professional
M!"0. OWNER-BUILDER DECLARATION
I hereby affect that I ver exempt from the Commcmr'a License Law for the
t•Z< rnllowing reason.(Seninn]031.5,Business and Professions Cade:Any city or counry' $20000
'I 0 which requires a permit to construct,alter,improve,demolish,or repair any structure
yam .P t t. sm ce I q_re theapplicant for such permit file asgned statement - --- - -
hacu haisliecincd punamins,t the potommus of the Contractors License Law(Chapter 9
(c ntmencin the tion 7000)of Division3 of the - 32S�O OFi `�O1��a.- Valuation
or that he is exempt therefrom and the basis for the alleged exeur cert rAny vio anon U ' i'
of Section 7031.5 by any applicant far a pencil cmern the applicant no a civil penalty
:of nm more than five hnndrea dollars(5500), 305 PN I�' . r Occupancy Type
❑1,as owner or the property,or my employees with wages as Deb sole compensation.
will ne theand
Prof ssi the surode T e i.s-not intended or eLaosred for sad(sec.701
1.an 6 01 — ROOF TEAPAgbF9.1'Inspections
Business aid Processions Code:The rovmmhereo License law does net apply m an
awnerof property Who builds or improves thereon,and who does such work himself
arthrough
tmsown employes,prnvidegthat such improvements weenotaskyearoe 602. ROOF .PLYWOOD .NAIL. .._
offered for sale.If,however,the buiave Ea improvement n sold within nee year or 6 03 - ROOF BATTENS "
momeletion,Ne corer-builder will have Ne burden of proving that he did net buil)or
prove err me mike clinic.). 604 - ROOF IN-PROGRESS _
_ _..
❑1 as owner of the with licensed comramors ro
property,am Business
ly cost g t
consmuct the Project
(Sec ]044 Business u d P fie inn. CWeI 7L<Conmanm'x r
L cense o does not apply man cone r property lin builds improves thereon,
and who contracts fhaw. h projects with a comra[mr(s)licensed Pursuant to theCroa -
131 mr crors Llaense law f I
❑lam exempt under Sec, PCfor this teas DECG�ecr Dae 12001
WORKER'S COMPENSATION DECLARATION
I hereby affirm under Penang of perjury one of the following declarations: ��I�®'��
❑ 1 have and will complain a Cenifcam of Consent to self-insum for Worker's
Compensation, as provided for by Section 37W of ,he Labor Code, for the
'ponfommnce of the work for which this permit is issued.
❑I have and will maintain Worker's Compensation Insurance,as required by Section
3701)of the Labor Code,for the performance of'the work for which this permit is
is. d My W rkei.x Co pe i 1 . mMc cartmp and Policy number are''
_..
.... II''..n^ L ...
Ca
mer s Policy NoWy��� it .. - 'v t
C RTIFICATION OF EXEMPTION FROM WORKERS',
COMPENSATION INSURANCE "
.(Th'suninn nem not be completed if the permit is for one hundred dollars -
ISIW)oness) .
1 c s,,I that n the perfor nonce of the wurk for wh ch subject
pe m t rs issued.1 - 4 -
shall ec employ any person ur any manner so es,m became sub3ect m tAe Workers
Compensation Laws of Califomin.Dam,
Applicant c.. ...
NO'PICETO APPLICANT,
afteri is C itoof Edemplomind
tiff mesubject tire Workers ompenstionp provisions the WorCaik.you must
00 fonhw ply with such Pmew..,or thispc Nhall
`
be deemed rooked.
F rn 'CONSTRUCTION LENDING AGENCY
1 hereby affirm that there is 5 construction lending agency for the performance
ti Q oftti' - . . .. 3099 C v.CJpnLe de Name
,r
U `7 I Tf'd :Il dll ,�,[ l da thin 'h Ibr t'lion i
IT+-Es c arect.l agme to primply withali city and county ordinerea,s and state laws relating
Q f, to building consumption.and hereby authorize mprkvcmruvcs-f this city enter upon
iy ri]
the b m ourned property to,inspectionp rp s
liabilities,
to indemnify and keep harml..s theCry fCpertino against
judgments, .r. d capenses which may in any way sernic against said
Viz City inICANTace printing of th L
SOURUCE R GU DSTTIONSN WILL CO COMPLY WITH ALL NON-POINT Issued by: Date
Signature I ApplicanUCnmme, Re-roofs
HAZAR S MATERIALS DISCLOSURE
y
Ili 'p rebuild' ant once,or R lineations us material Type of Ro materialOf .._.. .. .._.. ._.
as Jefi Jb the C pin nim 1 CW Chapter 9 h d the Huhh and Sarety .
C da-S etion 255320 �.:. ,. •. -' .
❑Yes y,oN All roofs shall be inspected prior.to.any roofing,material being,installed.
Will the applicant future building p t seeq :p t devices which If a roof is installed without first obtaining an inspection; I agree'to remove
emit hazardous air contam nants as defined by the Bay Area Air Quality Management
Dimer,^ all new materials for inspection. Applicant understands and will comply with
Elyc,- 1 0N all non-point source regulations: .
I have read the ham"ki materials requirements under Chapter 6.95 of the
C allhcfeornia Health&Safety Code.Sections 25505:25533 and 35534.1 undmosomhnt
huilding does not currently have a tenant,that it is my responsibility to notify the
accesses of the req whlah most he met nt prior to a of w ceni ickne of
G` °°`°` _ Signature.of Applicant. ... _ - _ Date _
uw a or amnonzea .I Date All roof coverings to be Class "B"of better
,. ., . .,_ _..... .. i OFFICE