03090181 CITY OF CUPER'1'INO ' '* k - "'� Tom, "I S^ '
BUILDING DIVISION PERMIT f,XONT"CJ, OR INFORMA�TIO .
nuILDINGADDRESS: RJL CONSTRUCTION COMPANY PERMIT N003090181
GWNERSNAME: 45973 WARM SPRINGS PERMIT ISSUE DATE
PHONE: (510) 353-0588 SANITARY NO. CONTROL NO.
RCHITEC'ENGINEER: BUILDING PERMIT INFO
BLOG E
__j 0 0LECT PLUMB MECH
l0
+00 LICENSED CONTRACTOR'S DECLARATION
{uF I hereby affirm that 1 am licensed under provisions of Chapter 9(commencing Job Description
SZty with Section orce and
efecDivixionJof NC Busincrs antl Pmfcssinns Code.anJ myliccnm is
j�? in irenll eClass arrant. REVISION--IN HOUSE USE ONLY
License Class Lic.x
ego Dat Continuator NO NEW PERMIT ISSUED/ORIG. #03040010
s ti ARCHITECTS DECLARATION
f W U I understand my plans shall k used as public records
o H Licensed Pmfcssional
jg OWNER-BUILDER DECLARATION
<5 1 hereby air m that I am exempt from the Contractor's License Law for the
O o following reason.(Section 7031.5,Business and Professions Code:Any city or county
<m which requires a permit to construct,a me,improve,demolish.or repair any swcwm
uZi prior In its issuanee.alse,requires the applicant fmsvch permit to Gln asignedsutemem
< that he is license)puri rovixinuoftheContractorsLieclsclaw(Chapter S Ft. Floor Area O
:moo p p ( p y. Valuation
ret— (commencing with Section 7600)ol Division of the Business and Professions Code)or
that he If exempt masfrom and Ire bus for Ne alleged exemption.Any violation of
Section 703 1.5 by any applicant for a permit subjects the applicant to a civil penalty of3 asN�� oO. __ Occupancy Type
not more Nan five hundred della.(5500). '
❑1,is owner of the property,or my employees with wages as their$ate compensation,
will do the work,and the structure is not intended or offered for sale(Sec.704t4,Business
and Profession Code:The Contractors Liceue law docs not apply to an owner or Required Inspections
property who builds or improves thereon,and who does such work himseBDr through his
own employees,provided thatsuch improsenenu arc not intended oroUered forvle.If.
M1Dweve6 me building or improvement is sold within one year of completion,me owner-
builder will have the buMen of proving mat he did not build or improve for purpose of
vie.).
Las owner of Ire Sec.property,em exclusively confessions Coil
licensed contractors i.
c merestLa me project(Sec.o an Business and Profusions ds or i The Confecaurn. nd
c e Law cts f not apply m an with
a of property who sed p rs improves Nonan,and
who acs for such pmjecs wire aconuactor(s)liceved pursuant mate Contractors '
License Law. \
❑lam exempt under Sec, ,B&PC for his mazon
ner
ER'S C ENSATION D RATION
Ow
I hereby affirm untlu n y of pe jury one of Ne following declarations:
Ej I have and will mainuin cnificate of Consent to self-insure for Worker's Compcm
satirn,az provided for by Section 3700 of me Labor Code,for me Performance of But
k for which Oris permit is issued.
I have and will mountain Worker's Compensation Insurance,as required by Socotra
00 Oldie labor Cock,for me prtformsnee of Be work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy numkr arc:
Cartier: Policy N., _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
This mesion need not k completed lithe Tennis is for one hundred dollars($ip))
or Loss.)
1 Certify mat in the peff r mance of the work for which Nis Permit is issued,l that not
employ any person in any manner sa az to rectum,subjcauo me workeci,Com,moution
Laws of California.Date
Applicant
NOTICE TO APPLICANT:V.after making this Cent Ocas of Exemption,you should
become subject to the Worker's Compensation previsions of the labor Code,you most
� z foMwilh comply with such Provererrs or mil perair shall W deemed revoked.
Z O CONSTRUCTION LENDING AGENCY
I hereby affirm mal there is a construction lending agency Int the performance of
Yr me .,it Cut which rets perm'.is issued(Scc.31017.Civ.C.)
21 Q Lenders Name
1' Landcr's Address
jz
;J Q 1 certify mat 1 have read this city
and county
and state chat the above information reading
is
yU Correct.1onagree tr cctcomply with ycityand coumyoNimnces and satslawsrelatingm
V 11
ing-menboacd construction.andhereby im,umonpurposesenulives of Out city to cater upon me
fZl ahovc-(We) 9 to saw,
emnify add keroscs.
•,,, p, (We)aguea.save,indemnifyandhich harmless Ire City of Cupcnst said
Cityy Iiaemoo,offer, thnos.ting expenses which may in any wayaccsuc against trod Cicy
J z A esanmq NT of he noting of this Pcrmll.
SOURCE GULDEROS ITDS AND WIL OMPLY WITH/ICJ NOj.6POV Issued by: Date
Slgrp�wrc of ApplmYnt/Comractpf/ ( // Re-roofs
HAZARDOUS MATEBIAU DISCLOSURE Type of Roof
Date
Will me a Collo or future pal Cs e,Chapter
r 9,1 at handle Health and
u se.&,by the Cupeninn Municipal Cada CM1epmr 9.12,and me Health and Safety
/'role.Section 25552la)7
❑Yes All roofs shall be inspected prior to any roofing material being installed.
1Il Nu
Wil Or applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
Omit hvardo.,oil CDnuminan.v defined by the Bay Area Air Quality Management
Di.,.? all new materials for inspection.
J
❑Yes Isd No
1 have sad the havaNnuussmaterials requirement under Chapter 695 of me Califor-
calmkSafctyCCxm.ScC ms M505.25533 125534.1undcrsuMtherifthe Wilding
dM}not centrally have a tenan4 mat it is p]nsibillty or nn11f the MCDPNt of the
requirements which est me suanw ora CcrtiOcau of easy.
Signature of Applicant Date
Owner aumorin ,agent All roof coverings to be Class "B"or better