01080031 OF
` CI BUILDING DIIVISIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
` 21230 HOMESTEAD RD BLD 7 ALL SEASONS ROOFING SERV CES01080031
OWNER'S NAME: APPLICATION SUB DATE
Am VILLAGE GREEN ASSOCIATES 2640 PACER IN 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
4089724455
q Q zo ARCHITECGENGINECR: BUILDING PERMIT INFO
ce— BLDG ELECT' PLUMB MECH
Qu
Nab
z y i LICENSED CONTRACTOR'S DECLARATION Job Description
O Z— 1 hereby affirm that I am licensed under provisions of Chapter 9 commencing
zas7 )orcoiis�ion3oorptheBusinessandProfessionsCodeandmylicen xa, is Sectionrce L9REROOF.f
of< Live
Lic.M aS?OQ� T/0, INSTALL OSB & COMP.
Date Contra or
L—� N ARCHITECT'S DECLARATION
LL y 1 understand my plans shall he used as public records
o O Licensed Professional
w,q trey, OWNER-BUILDER DECLARATION
I hereby affirm that 1 a nnpf from the Contrecmr's License Law far the
Y
?< following ressna(Section]o s rBusiness, tand Professions Cade:Any city or county'
$x❑ whichitsissuance,
srequires n permit re cores the alma improve,demolish, file
repair any swoon
i3- 'hat to hel¢censed pursareto quires provisions o for such Contractor
s Licenseaw(gned Cmcmem - —
(commencingwJpurstion7(he provisions n3ofth Business
andProfesvonsCor9 Sq. Ft. Floor Area nation
or that a log withpt therefrom
om a)d(he basis or t the Business mp Professions Code)
or thatheId 31.5 b therefrom and Thu basis for the alleged exemption.Any violation
--or hotSectione ban v any dreg am for n pemiif suM1jems the applicant m a civil penalty
'
or hot mare than five honored dollars Isswl. Ih Key Occupancy Type
111,as owner of the property,or my employees with wages as their sole compensation,
will do the work,and the structure is not intended or offered for sale(Sec.7064, 3 Q F3 - --'
Business and Pmfcssinns Code:The Conarnan's License law does not apply to an 3 07 - INSULATI161guired Inspections
owner of progeny Who builds or improves thereon,and who does such work himself I
or though his awn employe,'.pavi icd that sum impmvemenls re not intended or 601 _-., ROOF TEAR OFF
offered for sale.If,however,the building or improvement is sold within one year of
ompletian,theowirpoliilder will have thehookompovingthaf hedid not build or 602 - ROOF PLYWOOD NAIL
improve m"orpose of sale.). 603 - ROOF BATTENS
_ .rt. _ - _
❑Lasswnor
'he
propenyam exclusivelydProningnsColicensed:)ncomrenorsm 604 — ROOF IN-PROGRESS "
mthose the does
project(Sec. 1. Business and n, no
Coded The Cogimproves
the ters -
License Law does not apply man owner of popeny whn builds seimprove thereon.
.an0.who contracts foosuch pmlec¢wird a conuacmdsl licensed Pursuant to the
C mre License Law.
❑I amon exexempt under Sea ,B&P C fonhis
Owner Dae
WORKER'S COMPENSATION DECLARATION tI rf�
I hereby affirm under penalty of perjury one of te hfollowing acclarmions: I�0 II�I LS^U L IG 0
❑ 1 have and will mainain is Col ao of Consent o self-mune for Workers
Compensation, as provided for by Section 37W of the labor Code, for the DEC 11 2001 _
performance of the work for which this permit is issued,
❑1 have and will mairtmn Worker's Compensation Insurance,as required by Section 1 1
- 3]00 of to Labor Code,for the performance of the work for which this permit is BY'�DI��
issued,My Workers Comewrance
ption Insucar,a•nd Policy number are:
Carrier: t' Policy No,:'erW
CETIFlCA %EMNIh _D, RERS
COMPENSATION INSURANCE ' -
`,'
(This section need not he completed if the permit is for one hundred dollars - ""-
(SIWo or less.)
I certify that In the n in
maof the work for which this permit a Issued.I a'
shall en employ any person in nny manner go us m bcconie subject to the Workers'
Compensation nn Laws of Cnlilornin.Date
Appl"NOTICETOAPRICANrkrs Commakition p Cisions o of Lolver iode, ou-mshould
st
become subject o the Worker's Compensation provisions of the Whom Code,you must
z 12 forthwith comply with.00h pmvisionv nr This permit shall he Jamed revoked.
a.; CONSTRUCTION LENDING AGENCY
Ibreb afTn that there'sacn,, cral din f
of
'the work for x huh h 6 a8 ncy for the peedwance
y K us tss' a 15 309],Civ C.)
L Q Iend%rsNdb
1ltider'x AAAren
I lenity dun I hoe mad this a,,feah nc and ,are that We above inlurmatian is
F•, correct.I agree to comply with all city and county ordinances and state laws relating
4.1 to buildingconstmction.and hereby authorize representatives afthis city toederupon
2 ij:-ray the above-mentioned propcny for inspection purposes.
F.4s (WO agree to save,indemnify and keep harmless she City of Cupertino against
h liabilities,judgmems,cows nod apcnses whmh may in an,way accrue aBuinn said
ro
V z City in nsequense of be gramingbf this permit. �! /
SOURCENT UNDERSTANDSULi 'ILL CO.\IPLY WITH ALL NON-PONT Jssued by: Date
Signature of ApplicannCrmtmnrm " Data Re-roofs
HAZARDO MATERIALS DISCLOSURE
Wit the applicant or fu banding din*,stem or handl hazardous material -. Type of Roof
as defined by the Cupninoicipal Code,Chapter 9.12.and the Health and Sare,y j_: ,
Curie.Section
❑vex , 'ono ._ All roofs shall be inspected prior to any roofing material,being-installed... .
. Will the appl'c fequipment r f re building occupant use ordevice.which If a roof is installed without first obtaining an ihspectton,'I agree to remove
emit hoz dons dircontainment,as defined by the Bay Area Air Quality Flan gement
Districtall new materials for inspection. Applicant understands and will comply with
CI Yes ❑N" all non-point source regulations..
1 have read the hermdous pressi s requ nparems under Chapter 6.95 of he `
California Health&Safety Cade.Sections 25505,25533 and 25534.1 and...andfant
if the building does not cuncally have a tenure,that it is my resPonsibiliry o pacify the
.,,Paul of The he" mrn be met prior to issuance of a Certificate of
Occupm,cy.
- Signature,of Applicant .- Date
Owner oraalhari.od agent Dale All roof coverings to be Class "B"or better
.. .. OFFICE - ...