01080038 CITY OF CUPERTINO
4 BUILDING DIVISION6'ERM.IT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
21230 HOMESTEAD RD BLD 3 ALL SEASONS ROOFING SERV CES01080038
OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO,
4089724455
GW ARCHITECTIENGWEER: BUILDING PERMIT INFO
m— BLDG ELECT PLUMB MECH
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Z 8 m_ LICENSED CONTRACTOR'S DECLARATION Job Description
O z_ 1 hereby vffrrn Nat I am licensed under provisions of Chapter (commencing
F,:s-u with Section 7")of Division 3 of the Bu.sines and Pmfessons CWe,and my license REROOF. '
�
Yg3 z z¢ Lived e Class Lid.i,infaurnreeanaeffen
� 7 79-190-7/ T/O INSTALL OSB & COMP.
sN X
,5300 Date Contractor ������®
F-p p ARCHITECT'S DECLARATION
I understand my plans shall be used es public records
�a
z Licensed Profersional
n'y'eLL OWNER-exemptRmt the DEC 11 2001
t�i ^ I hereby affirm that 1 am exempt from the Comma Co License Law for the
F z fallowing reason.(Section construct.
Business and Professions Code:Any city structure Y es which require,a permit re construct,almL improve,demolish,or repair any structure
a3 Pot heor is
lensed pursuant to theres movisiocamfar Cortioach rmiuofilnsee a Law(Chapter
Chaptestatemem --
ttaurna pong.it pursuant t6 the provisions Division the he Bricmrs License Lawcar,C re) _ S'q. a UBIIOn
(commends exam Sermon ord and tebaiso of alleged
ss and Professions Cods)
or thathe7 31.5 b therefrom and the basis far the alleged exemption,Any I Pennon
of Section,than
r anyappl dred ollfor apermit subjects the applicammocivil penalty
:mrnnt more mon eve honored dollars($503). ufiber . Occupancy Type
❑1,as per of the property,or my employees with wages as their sole compensation.
will do the work,and the svucwre is not intended or offered for.sale(Sec.7044,'
Business and Profession,Cale:The Contractor's License Law does not apply to an 3 07 - INSULATIFUWUred Inspections
owner of property Who builds or improves thereon,and who does such work himself
or through his we employees.provided that such improvements are not intended or 601 - ROOF.-TEAR, OFF_
offered for We. however,the building olimpnwemem is sold within one yea,of ,
completion,the owner-Mulder will have the When of proving that he did not build or 6 02 - ROOF PLYWOOD NAI L� � -
improve for purpose ofade.). 603 - ROOF BATTENS
. _ . ._ _- .
D I'u mw fifer propeny,amexch ''elyc tract ngwth fcenseJ course to 604 - ROOF IN-PROGRESS
construct the project(Sec ]044,Business and Profess ons CNet)The Communist's
License Law does oat apply to an owner of property who builds or improves thereon,
andwho contracts foosuch.projects with a comractorls)licensed.parmant to the .. - .-- ..-.. .. .. .... .__ ._.. ..
Lieen.se Law.
0 1 dra csc .�
O I am exempt undtt Sec. � � ,0&P C for this reason
owner Date ..
WORKER'S COMPENSATION DECLARATION
1 hereby M.order penalty of perjury one of the following declarations:
- ❑ 1 have and will maintain'aCertificare of Convent to.self-insure for Worker's
Compensation, as provided for by Section 3700 of the Labor Code, for the
performance of the work for which this permit is issued.
❑I have and will maintain Wmkers Compensation Insurance,as required by Section
37W of the Labor Cale,for the performance of the work for which this permit is
issued M o/kers C pe at(n Insum ce carr er rid Policy num7berLarcy: �
Carrier 1W, ':...Polcy No: tl.C3ao�, M' 1�7�� ".; Fa r
�CERTIFICATIONOFMEBMPnONFROM.WORKERSI' -
COMPENSATION INSURANCE ........
(Thu,semimpa,tal not he completed if the permit is for one hundred dollars
6100)or ess.) .
1 certify that in the p frmank ciffibe work for which this permit is issued.1
shall not employ any person to any manner sn as to become subject to the Worker,
Compensation Laws of California.Date
Applicant -
NOTICE TOAPPLICANT:If,after making this Certificate of Exemption,you should
become subjecrtdthe Worker's Compensation provisions or the W Mr Code,you must
O forthwith comply with such provisions or this pemtit shall he deemed revoked.
... .. .. .... .. .. .. .. ....
Ca,jQ - 1 CONSTRUCTION LENDING AGENCY
hereby that there co on lending agency
for for the performance which this pe nu is issuedEed ,097,Cie C)
Under',Name
�-z Lender's Addrcav
V � ,t 1 mortify tont I have read dos ay and oo and Maw nota the ohms maws a lati I,
Lia ['ter tomecV 1 agree m comply with ell city and coamy,chno , and airy laws relating
� f,) the dro -uncru ardprpndhereby authorize mWw'. tivys ofthis city menmr upon
(� the al+o(We)agree
to property 1'or inspection puharmle.
��yy ps
(We)agreemsave,indemnify and keep harmless the City of Cupertino agaimt
F4 V] liabilities.judgmentcosts nd expect e: h ch y ar any way accrue again,said _i
City in c p",neree f the g ming of .�
APPLICANT UNDERSTANDS AND,I LL I"fWITH ALL NON-POINT Issuedb Dale
SOURCE REGULATIONS. ' y:
. Sgnamrcpf Applica JC t to Date Re-roofs
HAZARDOUS Megcopunt
S DISCLOSURE ,Type Of ROOF ---
.
Will the appl t ft build tore nr handle hamrdoas mateial as defined bythe Cup.nino Mun etre Chapter 9.12,and the Health and Safety 1
Code.
d Section 8532pmJ... _ s,•
°M1 ... Allroofsshall.be.Inspected prior to any.roofing.material_being.installed.
W .-_.. .. .
ill the appl t r f t building e ,pat use qa pate t or device,which If a roof is installed without first obtaining an inspecnon,*1 agree to remove
emit h a ,tarcontaminants a,der abymeBayAr aAtrQaalty.mnagement' all new materials for inspection. Applicant understands and will comply with
ore,.-- ❑No - all non-point source regulations..
1 have ad'he hazurdm:s materials requirn war,under Chapter 6.95 of the
California Health&Safely Code,Sections 25505.25533 and 25534.1 understand that -
if da building dues nm currently have a timet,that it is my responsibility to notify the -
tiecupam of the requiremems wti must met prior to Is<nored of a Cenificme of.
°"app°`y" Signature of Applicant _Date
Owner mpmh rrizea Agent' Date All roof coverings to be Class"B" or better
OFFICE