01080033 CITYILDIN DIVISION CONTRACTOR INFORMATION:
n PERMIT
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD PT # F ALL SEASONS ROOFING SERV CES01080033
OWNER'S NAME! APPLICATION SUB DATE
AVERY CONSTRUCTION 2640 PACER IN 08/07/2001
PHONE: SANITARY NO, CONTROL NO.
4089724455
O O ARCHITECTIENGINEER. BUILDING PERMIT INFO
{Y {p BLDG ELECT PLUMB MECH
FyF<6 =_J
Z O h Z LICENSEI hereby f'.'hot IDamlicensed uad,, DECLARATION ,Job Description
oz_E 00 !nnprovisionsof Chapter.rcommencmg TEAR—OFF TORCH DOWN
wnh fall fore and of Disisi 3 Little Business d Professions Codd.and my license
se f is in full force and etre _ j r
K re 6 License Class Y Lic.k
3 y Date Contractor
ARCHITECT'S DECLARATION
t= O 1 understand my plans shall be noted as public records
�N
a n o O Licensed Professional
n
OWNER-BUILDER exempt from
1 hereby a(Srtn that 1 am cxcmpt from the Contractor's License Law co the
(:g n following reason(Section 703L5,mousiness and Professions Cale:Any city or county" t $3000
g 0 which requires n permit ca eery the,aper,improve,demolish,or repay any structure
n e that
t t e al. carriers N ilio applicant for hpeon It issignedstatemenb --
th th I' rip r n the provisions ftp Contractor License Law(Chapter 9
�pJ�tO r r�a , Valuation
(commencing withS to 7")of Division 3 ftp Business dProfessions Code) 32S AA19F8,
or that he i4 exempt therefrom and the basis far the alleged exemption.Any violation
of Section 7031.5 by any.,pit..for apermit.whjects the.,,Ilearn m a civil penalty
.ofnot ortmanfivehundreddollars($500).
m305AP_NM t OccupancyType
❑I,as owner or the property,or my employee,with..,as as their sole compensation,
will do the work,addtheawcmrc'C norctor'sintended or se Lawered for snot apply toa n 6 01 - ROOF TEAI1E949tP4I' P
waxiness and Professions Code:The Corn narear License Law docs not apply to an Inspections
owner of progeny Who builds or improves thereon,and who inexistent work himself
ar through tax own hat ever,t building
mat Inch improvements is sol ore not intended or 6 02 .-. . ROOF. PLYWOOD .NAIL , -
-compiofferale fill rale.If,h ih nuiave t e burden
ofams Id within one year of
o pl eo ,the owner b 'IJ II have the burden of proving that he die not buil)or 603 — ROOF BATTENS
mprayeorpapnearamt.l. 604 — ROOF IN—PROGRESS
:J 1DIaz owner of,M1c „. .. .._. ._. ._ - ,..
p p y excaliled,contracting with licensed comrncrors to
bn"me.rhe proyct(Six.7051,Business and Profession nCrude)The Cont.mr's
License Law does not apply to an owner of property who builds or improves themon.
:
-Ac”,
antlwha.ccontacts.or.such.Projec¢with.a coatmcmgs)trimmed,pursoanLto the ..,. _"_.__ ,. ,..._.._.. _... ... . ._. . ... . .... ...
C [meat
License
nsc
❑lam ptunder5 '� ' ,B&PCfar this remon
Data I�ONNl�If�[ DD
WORKER'S COMPENSATION DECLARATION q
'! I hereby affirm under penalty of penury one of me following declarations. DE/S 11 2001
❑ 1 have and will maintain a Certificate of Consent m self-insure or Worker's l/
Compensation, as provided rot by Section 37W of the Labor Code, for the
parformancrofthe work forwhich thisperrnit is sued.
BUILDING
❑1 have sand will maintain Worker',Compensation Insurance,as required by Section
3700 of the'Labor Code,for the iterformance of the work for which this permit is
issued Myyyy//'9'9 �e� q�d
Car r•lII.'�}TIFOL43-', OP EXEMPTION FROM ... .. --. .., ,•,,.,•. •.,, ••
key's C m e ton Inmmnce comer and Policy n taper arc:
�ER
.. . q. .... .....
COMPENSATION INSURANCE'
(Ths se Lha need not be completed if the permit is far one hundred dollars !
(SIM)or less.)
.Ic nfY thain the faclomIancecifthe workfor which thnibs issued l
shall not employ any per on in m beta rte sub object to the Workers'
Cot6pemsation Laws of CaliforniaFare
er so us 3
Applicant
Formed
subject
uj APP LICANrkar's this Cenins of
of Umor Code,youhould 's
forthwith comply
witW rk .Compensation ip oasofine Lnedr Jik y'. must
z O' p y with h fari.'uns o this permit shall b d d - -
4 CONSTRUCTION LENDING AGENCY
�' I hertar nn that the on.t t n lend ng ag y for the perfomiantt
: c
-w, of the work for which In,pe Tis issu ad(Sec.3097:Civ.C) t
loode,'9,Name
Lenders Address if I Lill
1 eel Lily tlmll nod Li%upPl locion oled stloltlm tire'h houldtLoll 6
kT+ F cancer.1 agme to comply Mill all city a d emem,lunfiraince, .it.,Lee laws mita ng
to budding construction,and hereby authorize representatives ofthiscity to cretinism
the above-mentioned property for inspection purpae.s.
E+ 4 (Wo agree to save,indemnify and keep harmless the City of Cupertino'against '
Vi liabilities,judgmems,costs and expenses reach may in any way accrue against said
City in consequence of the gmmingpp�is permit. "'�
APPLICANT UNDERSTANDS A fftAV L COMPLY WITH ALL NON-POINT
SOURCE REGULATIONS.' Issued by: Date
Signature wfAppheanvcomrdnorData Re-roofs
HAZARDOU ATERIALS DISCLOSURE
N''I1 me aPPlirm r rf w riding racciparn wore or handle hazeNuus metrial Type of Roof. - - - .._ ... ... .. ... ..... .. ....._ ,.... .. ..,... ',
�C de Section 255320 Health and Safety „ `
❑Yes. . . El No
as d fined by the Cup m Municipal Code Chapter9.12, d the
All roofs-shall be inspected.prior to any roofing material being installed. ....__ ..
Will the applicant or future budding occupant also equipment or devices which If a roof is installed Without first obtaining an inspection, I'agiee to remove
unit hazardous noir¢mtaminan¢as defined by the Bay Arca Air Quality Management
Cannot^ all new materials for inspection. Applicant understands and will comply with
❑Yes .. 11 No
all non-point source regulations.,
1 have read'.the hazardous materials requirements under Chapter 6.95 of the.
California'Health&Safety Codd,Sections 25505.25533 and 25534.1 understand that
t t e building rices not lurrently hsve a must
he met it is my responsibility to notify the
oc pa t of the reyp e s which muni h rpriar to ` -f h Certinwte of
txapa y.. Signature of Applicant _ Date
,loor.ornalh..aad- t Date All roof coverings to be Class"B"or better
i
,.. :. .. . OFFICE -_ .._.-._. . . .. ._