01080036 .l CITY t OF
cc DPv DIVISION CONTRACTOR INFORMATION:
PERMIT
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD BLD 5 ALL SEASONS ROOFING SERV CES01080036
OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
4089724455
p p FEIENTIENGINEER: BUILDING PERMIT INFO
kL"w BLDG ELECT' PLUMB MECH
w LICENSED CONTRACTOR'S DECLARATION Job Description
OZ ln hy af0sm Nal 1oat licensed underprovisionsofChapter9lcommcncing
'A1_ 70001of D'ylldm3ofNe Businarmul]2p/-TOessio.a.Codc.and my license REROOF.
rte anJ c '7> f� 1eepa, ss '639 conaaclor7> / T/0, INSTALL OSB & COMP.
0.� ARCHITECI"S DECLARATION
d C 1 understand my plans shall be used as public records
d i
to y ns
0 C Liceed Prolbssional
°'�Siff OWNER-BUILD17R DECLARATION
1 hereby infirm Thal 1 a'm tsculd fmm the Cmum,ror's License Lis,forthe
!Z Q following mason.(Section 70316.Business and Professions Code:Any city or county"
Y,x G which requires a permit m construct,altarimprove,demolish.or repair any structure,
3^� prior to its issuance.also requires the applicant far such permit in file a signed statement - -- -
tbar heislimnsedpurmanftothepmwsionsof the ComuctWsLicense Law(Chapter 9 Sq. Ft. Floor Area a uation
(commencing with Section?000)of Division 3 of the Business and Prnfead.sCode) - j, 5
or that he is exempt therefrom and the basis for he alleged exemption,Any violation
of Section 7031.5 by any applicant for a permit sobj.ts the a,licanuo a civil Icnalry
of not mom then five hundred dollars($500). nlbe Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation:
"'will do the work,and me structure is not intended or offered for sale(Sec.7I44, 305 -
Ravo dand Professions Code:The Contriewl's License Law does not apply to as 307 - INSULAT IPSRtttred Inspections
owner of property Who builds or impurities thereon,and who docs such work himself
or through his own employees,provided that such improvements o2 not intended or 601 ROOF -TEAR TEAR OFF..... , _._. _ _. .... .... _ . . .... __ . ..
;dfferer for sale.If,however,the building or improvement is sold within one year of
compinion,the owneolmilder will have the burden of proving that he did not Wild or 602 - ROOF PLYWOOD NAIL''' ' ''
improve for parpoaerdaale.). 603 - ROOF BATTENS
_. . N ---
_ ❑Las acne papiecof or,property.am a Business
and Professions h licinaved The mracmrs m 604 - ROOF IN-PROGRESScouldru
License the does
no(See. too0fL Business and ProfessionsColor The Con tractor's
ad who
Low does not apply to an owner of p comp who builds or improvesthereon.mhe `
and who connacta for such pmj.ts wird a conuacfans)licemd pursuavt m the
01 a.exempt
ante Law. II— II V/1'U 11m lSe D
' ❑lam exempt under Stt. ,B&PCfor Nis revson .• ' 1 ` � n'r "
Owner Date - - DEC 11 2001
WORKER'S COMPENSATION DECLARATION
:.-• I Fell affirm under penalty of ,jury one of Ne following declarats:
ionBUILDING p�/�
❑ I have and will maintain a CcriiOcane of Comm 1.self-ms.re for Worker's BUILDING
Compensation, os,provided for by Section 37W of the Labor Code, for the
performunce of the work for which this Permit Is issued,,
❑1 have and will maintain Worker's Compensation Insurance,as required by Senion
3700 of the Labor Code,for the performance of the work for which this permit is
ultmd.My Wo rx Compenvtion lnxumm'e,artier and Policy number are:
C.icr:VYlliW✓VII' l.. •Policy Nii 000 1W11 y
(' CERTIFICATIONOFEKEMPTION FROM WORKERS' - -
. :. COMPENSATION INSURANCE" .._._........_..a
Mis section reed Two be completed if the permit is for one hundred dollars C' ;I'
($110)m le.1
1certify that hathe performance of the work for which this Poold is issued 1 '.
.half aid employ any person in any culture,or as to bcrome omitel or the Workers
Compensation Laws of Califamia.Dura'
-Applicata _
NOTICETO tIn the Worker,Ctrmuattimthis Ccnlnsofof LpdptcAdyou should
bttmme:a comply In
Workefs Compensaion previsions of the Lahbr Code,you mon
O forthwith comply with such pmvixiom or this pttmit stall be deemed rtvaled.
F'� CONSTRUCTION LENDING AGENCY -
C -1 hereby alPom that them is a ransauaion lending agency for the perfomunce
of the work for which this permit is issued situ.3097.Civ.C.1
Lenders Name .. ...
y0 -. " . ..
J 1 renis lot I Lave ,,,it This ilgillcauon and.vane that me above infuriation is
�a-E• correct.1 agree to comply with all city and county ordinances and"
ae p
laws relating
D.�V Iohuildingconslrrinion,and hereby authorize'rep,esentatives ofthley citmimoram
:a, the id,ovcmenti.ned property for inepcaimi urco s,
E.O.d (Wc)ag,eemour.imilumifyard keep harmless Ne Ciry of Cupertino against
'In liabilities,judgments,costs and expenses which may in any way accrue against said
City in consequence of the placing of t is permit.
APPLICANTUNDERSTANDS ND ILL COMPLYWITH ALL NON-POINT
SOURCE RBGULATIONs. ' - Issued by: Date
Signemmaf Applica `Cantron Re-roofs
.. HAa MATERIALS DISCLOSURE
I. ed l the by
Cupent. building.cuhaw"oremand the ealloand Safety Type of Roof. - -... .. ....._
C deGnN by Ny!02(0 in unicipal Code.Chapter 9.12 and the Health and Safety
Cdde.Sution 3532(gl^^.
oven. o No _All roofs shall be inspected prior to any roofing.material.being installed. ,.. ..
Will the applicant or future building occupant umequipmem ordevices which If a roof is installed without first obtaining an inspection, I agree,to remove
emit hamrdous air contaminants as relined by the Bay Area Air Quality Management
Diariel" all new materials for inspection. Applicant understands and will comply with
area ❑No all non-point source regulations. ., -
1 have read the hazardous materials requirements.under Chapmr695'oT the
California Health&Safety Code.Section 25505,15533 and 35534.1 understand that
if Nebudding does not currently have coccum,that it is is,responsibility fructify Ne - - - -
.,.,an,of the requirements which mustme Grior to Is.ance of a Cenificate of
occtga.y. - Signature of Applicant Date
t
Owne,o,as Waked agent - Date All roof coverings to be Class"B"or:better
I OFFICE