01080041 4
jCI BUILDING DIVISOF ION NO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
,) 21230 HOMESTEAD RD PT C ALL SEASONS ROOFING SERV CES01080041
OWNER'S NAME: APPLICATION SUB DATE
VILLAGE GREEN ASSOCIATES 2640 PACER LN 08/07/2001
PHONE: SANITARY NO. CONTROL NO.
4089724455
re0 ZQ ARCHITECT/ENGINEER: a BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LJ I__A L__D LI
'Z 6v=et z LICENSED CONTRACTOR'S DECLARATION Job Description
Z_G 1 hereby affirm ilia 1 am licensed undo provisions of Chap¢r9(commencing
.ma with Section 7000)of Division Sof the Business and Professions Code.and my license REROOF.
In full farce and che" �—9�
�sla ii«nae cm.aa �7_ uex 7S9o9/ T/O, TORCH DOWN.
a. Contractor
t.LL G Dare ARCHITECT'S DECLARATION
N
— ,g 1 understand my plans shall be used as public records
�
o O Licensed Profosiowl
c o OWNER-BUILDER DECLARATION
I Needy antero on I sin exempt from the Cessions o :Any c ty o for the
F Z a following action.(Semon 703L5,Business and Professions Code:Any city or county'
e
E ❑ which requires a permit re answer,alien improve,demolish,or mash any nmmure
prior heir ismsext p,alsorequirenhovisioanf for mchpctors Licensle ae Law(Chapter
of the Sq.FL Floor Area nation
(commmcis a with Section om and
Division o of the Business and Professions code) ,
of thatheis exempt therefrom and rhe basis for the alleged exemption.Any violation
of Section 7031.5v any dre di for apermit xubjegs the applicant macivil penald Occupancy Type
of oat mare man Ewe hundred dmmra($5oo). umber .� . .
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.713U, -
Bu3iness and'Professions Cade:The Contractor's License Law does not apply to an 307 - INSULATIftuired Inspections
owner of property Who milds or improves thereon,and who does such work himself
or througgh his awn employees,provided that such improvements am not intended or 601 , -.- ROOF..TEAR..OFF-.
off red Tor sale.If,however,the building or improvement is sold within one year of -
impletion,the owner-builder will have the burden at proving that he did not wild or 602 — ROOF PLYWOOD NAIL
improve far Pumn,e°fail`')' ,- 603 — ROOF BATTENS
01.zs owner of them n .._ .-... __ _ .._. _.. . ._.
p p_ y,-am exclusivelycontmningwithlicenandcomecmram 604 — ROOF IN—PROGRESS '
constrain She Pat(Sec.7014,Business and Professions Code:)The Contractor'sLic
and wh law docs not apply man owner of property ra who Wilds a improvesthereon,to dr, /nl tf fr�
..and who contracts for such Projects with a commemrts)licenud pursuant m the
Convacm/s License Law.
°Iamnxerain rode,Sa. &P C far this mason DEC 11 2001 a
Owoar - - nam
WORKER'S COMPENSATION DECLARATION• p�/1 Ihereby ailurounderpenaltyofperjury one ofrhefollowingdeclarninm: BUILDING
° I have and will maintain a Certificate of Consent to self-inane for Worker's
Compensation, as provided for by Section 37W of the Labor Code, for the
pstformnnce of the work for which this permit is issued.,
°I have and will maintain Worker's Compensation Insurance,as renamed by Section
- 37W of the Labor Code,for the performance of the work for which this permit is
issued.M�y/��'p_(a Compeasnion los vrrierand Polity num-hyer arye:L� _
Carrier:v s l l (�(// f Policy No.:WC�T Yf/ //�
c -
.CE LPICAIIUN FROM WORKERS'. ' \
COMPENSATION INSURANCE'.,'
(This section need not be completed if the permits for one hundred dollar
s(SI00)o lessJ
1 certify thin in the performance iitis wok for whichi jsubjectpermit issued.1
m rso
tr 1; '•.
shall nemploy any pen in any mannar so as m become subject to the Workers'
Comicant an Laws of Colif9mia.OraeAppl ' '
I'NOTICE TO APPLICANT:IL CmrPcmmg this Ccoilieale'at Exemption,you should
Z becontecuhject mthe\Yorkers Compensmion provision,of the LAW,code,you must
Zwrte 0 forthwith comply ith such provisions or this permit shall deemed revoked.
E' CON STRUCTION LENDING AGENCY
1 hereby afire that there i,o tt,nnmetlon lending agency for the Performance
wQ of the work for which this permit is issued(See.3097,Civ.C.) - -
L -Lcnder',Nae
Lcnder'n'Addi ,
V I cetlify that I have teal Thi,application unJ state that[tic above moonation is
tss:Ew correct.1 agree to comply with all city and county ordinances and sum laws minting
c V to building construction,and hereby authorize representatives of this city to enter upon
96 the above-mentioned p save,
indemnify
for inspection alike
} purposes.,
[r Or es,tl agree ts save,indemnify and keep hatmlces the City of Cupertino vpainst
rA liabilities,judgments,asrs and expenses whic may in any way aceme against said s
(.) z
Cir in'roreeyuence el the gntmin,Nof 't pe 'n.
APPLICANT UNDERSTANDS AN L .O V WITH ALL NON-POINT
SOURCEREGULATIONS. Issued by: Date
- Signature of AppncSMeommemr Date Re-roofs
HAZARDOUS MRIALS DISCLOSURE
Will the aPi licam or frdire bui g brcuyantsome or halm htiarJuus.6.1 Type of Roofas deOneJ by the Cupertino Munici We.Chapter 9.12,and the Health and Safety
Codc,Sectien;5532(aR ., .a, S
❑res' o ,,.r r All roofs shall be inspected.prior.to any roofing materia] being installed.
• Widthe applicant o future buildig occupant trsc equipmentordeviceswnm If a roof is installed without first obtaining an inspection;I'agree to.remove
franharardoux on contaminants as ecl d by the Bay A A Quality Management
D t t all new materials for inspection. Applicant understands and will comply with
❑Yea ON. all non-point source regulations. _ , -
1 have read the huzadoo,maerials requirements under Chipmd6.95 of the.
California Health&Safety Cade,Sections 25505,25533 and 25534.1 understand chat
flhebutofte currently that itism issuance responsibility lonocare of, --
occupant of the requirements whic usl t5Ac,prior m issuance of a Ccnifnare of
Occuparq,. Signature of Applicant Date
All roof coverings to be Class"B"or better
2�rscr or authorized agent Date
.. - .. OFFICE .- ...._.... _. _.. . ... .. ... . . _