01030139 CITY OF CUPEWrINO
BUILDINC DIVISION PERMIT CONTRACTOR INFORMATION:
HU...DING ADIIIiESS, PERMIT NO.
PL 01.0301.39
OWNER'S NAME: APPLICATION SUR DATB
03/22/3_001
PHONE: SANI'T'ARY NO. CONTROL NO.
O C Z ARCHUTCLI NGINI ER BUILDING PERMIT INFO
O O BLDG ELECT PLUMB MECH
y!a F
y 5 y' LICENSEI,.,I acro Itdood I,.... CLAItATION Job D0SC1'Ipl10n
w E I hereby af0 I' Ibm I um licnhscd,Inner pony lanae 111CMIpmr9(enmmeneing
F � IthSccd...1700)MDivi,lon 9 of the It I,,redlProly I,,Code,and toy locale
Q ? inln l all l lmc Flat clTen.
w a L"' "Cla e I.ie.w PANEL UPGRADE TO 200 RNP
3 s, nam Caulrneen
4 O ARCIII'I'FC'I"S DECLARATION
I rrdrrnumA Icy 11a,shall he u,'ed a'pnMie recordk
po IJI,o t1)Pa,fes.ionul
XOWNER-BUILDER DECI.ARATI ION
W= I hereby affirm hall I tam exeaapt Imjo the Cmnrncl-''x Lfcmou Luw far one
k Z�, follel ing reason.Scrot 71615,nusilleea ur,l Pml'aeions Code:Any city or carry
SS G
Mnch retain,a perrall an oal Iher,iniprove, I I'I or lepain-any%rFmm
Iy3m ,, bo 1 'I. t1w applaIIorloneh1lieraii to[lie a ligned.em et
L Irt he Pl IeenedPeFl a it)the pr,v.a ft ('011ineiren N I i LILW(Chattel 9 Sq. Ft. Floor At. Valuation
(... I e wing will,Start....7000r of Division 30 the Bn...r,,end Pvnicslmu Code)
or[III[Ire 11 exempt mercleall a,Id dee areal,rhr ma reneged extortion.Any initiation $1500
rseclirl,711 L5 by Illy apphen't for 11 p,rnat amiens Ire am,lialnl to a civil,Crary
of not more mal,five barrow dollars($500). A PN Number Occupancy Type
❑I,l nwncl'iflheprogeny.Italy nnpbyeen wino wase'as their.'OI„omnperranon, 1067. IAIA
will do Inc wnrk,and Inc 11111111111 I'11111 Intcntw or Offered for sale[Sec 7044, -
Bb'insl and PrabIlI an,Cl aerme C11nlnlnel x Lica11'e Law doe'noI apply It,an Required Inspections
Iu r Ifpropony Who builds'OI'ime'provlhel'can,!'Ili Who dors inch wtak hlm..It
teronglll [its two cnployeesplelld,dhat suehimproventenlxare not anointed oi 304. — ROUGH ELECTRICAL
Millet tor sale.11,Lnwev.q de bidding or impravuncnl i'11)[11 within on,year of
FWnnpiebn011111nwnl-baAL111Widbmedlebarren ol,.......Fort hetRIIIran 111 501. — FINAL ELECTRICAL ENERGY
imp ee,for prapa,00f mica.
❑I."rwaar nn I.,aarn.non r.eblxivel raenn 'nl E,eas,d.ananar,m 505 FINAL ELECTRICAL
s O
d p , ,n 7044 B d l ,C ) C m11mo,s
Ike 1 or Inch t 1) Y 'I lull I' _ILe,til
'Ind I: r Inch pr feel. aIle l all'el r(E p 'I,I Ir tile
El /�.
❑Ian, Icar,a rotor Sec ,Rkl'C rnrpaie ru.n
Owner Ilan �®
WORKER'S-CM PENSA'CION DI CLAItA'rION /
I I hereby affirm ander pcmdty(it incialy one aIle,falI.,in,dnian a nr
t t
❑ I In, nd will oltionsill4 Cellificum or ConsaFl w sell-imam in Worker's
Compe11culon, as poided fnr by Section 1700 of lbe Lxhor Cede, for the
P,Lannarl the orad-for which IIIb pcnnit is InO al,
❑I have and 04111 Iannodo Worker CoanpcndFl Ion In"Fer",Iiss I.Gait'll by Sermon
9700 01 the I.ablo Code,Ior the Porbortnanco II the wtak for which Ihi' nnit Is
usd.My Weak,,C... acr,nlilIr'nnmce earlier land Polley number air
Carr— Pulley Nor.
CEIIA IFICA'I'ION OF IiNEMPI'ION FROM WORKERS'
COMPENSATION INSURANCE
r hix,ocrar real nal be enorplemd if the gelnail Is brine bandrnl Jolmrs
(1[00)n,ac's.)
I...Illy taw in the ad one",II the work for which Ihi,permit is issued,1
shall bol employ Illy Peron m any Fo na,aO rx m heconto nadieFl ,I the Worker'
Compenxallon Laws of Cabfomla hire
APPllcunl
NOTICE OAPPLICANT:If,Filter nwking his Cetlitierao of Fxemplior,youshoWd
onallO'rbicct to the Worker,Conp,cnrniun provi'iono of dm LA Cuda you jobs'
Q ruabwith comply with nee,Pmvi'iam or this pennll shall be deemed revoked.
Z w.
CONSra,LGa'ION LENDING n AGENCY
I herby Which mal Ic,ni is a mmllmdin11 097,g Wguncy rnr the Perf11m,11ncc
tithe wnrk fnr which this pennll i.'isxncA(Sou.4097.Cie C.)
W Q herder',. dore
;5header'sA
� header's Address
V 1 cel ily all I little mW Ili'applicolion and,tale Than the abhve mfmmadun is
I, t", c rYel,1 agree m comply with all city and,arty hrdinnnecs Wad 1111101ass elating
V r,building constmellon,untl troche emthorlse reptnutalor-Fir thi,alry III enter upon
the above-mennaned propary rot I-Prel an putpunul.
Fes., d (We)agree to snva ademnlfy lmd kelp ball F1111 the City Of Cnpcnlno against
V4 liabilities,'I udgmenrs,Faris and expen,ee w[ndI may in any Illy I111to Firroall'aid
,Z City in cohsn[acaoe if lac staring FI l hl,Pcrmil.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON POINT Issued
SOURCE RF,GULAI'IONS. y Date
Signaalre of ApplinnWCammcmr bale Re-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will me nppbnlm Fir 11 c building rknaplint Note ar handle hlallldro,I,telial Type of Root'
a'defined by IIs Cbgenim Man'miprl Cndc,Chil9.12,and Inn IRaIIII I I Sorely
Cede,Setmn 25592Ud:'
°1`" 11No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant r mmle mdlding ae<agall nacalnipa ar n,de'l.,'hien If a roof is installed without first obtaining an inspection, I agree to remove
emit ha'loo ons I,,FanOminand its dclined by the Tiny Area Air Qunlhy Menrgenaent
Do16,t11 ❑Nn all new materials for inspection. Applicant understands and will comply with
all non-point source regulations.
Cantor lihull fend the b r,,,ka s rnlurrials ncioner ral,ander Ch,ler 695 of the
a Health h RAty Code,Se..iuns 25511.5,25533 trod 25530.I und,roand Inn
it the huildsg docs net carmn0y have n Fora,that it is my IxxpansibilityIo 11wlfy the
cul and of the rerini en abnIn
s which Ist be cl prior to sen
ree all Cenificale of
o"open y' Signature of Applicant Date
Owner n,aatharund ,,at Hire All roof coverings to he Class `B" or better
OFFICE