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CI'T'Y OF CUPER'I'INO
= CONTRACTOR INFORMATION ` -
BUILDING DIVISION YFRMIT
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BUILDING ADDRESS:
ABLE SEPTIC
PERMIT N®4100095
0444 S BLANEY AV
OWNER'S NAME:
PERMIT ISSUE DATE
TEE HIRATA
520 REED ST.
10/14/2004
HONE
SANITARY NO. CONTROL NO.
(408)377-9990
ARCIIITSCT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 hereby Chapter 9
lob Description
p
affirm that 1 am licensed under pr is;uns of (commencing
with5 tion]IXN)nf DivixionJof dmBusinc'imfcx inns Codc. and my license is
in ml dcrrect.
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SEWER LINE CLEAN OUT SEP gN4�al]i},Ta-INISL�1\(I
Dam `A'aCumncmr A.'
I untl�c-urs d as tiblie,c
OCT Z7 2004
Lkcnscd Prafcxxmna
OWNER -BUILDER DECLARATION
1 hereby affirm that 1 um exempt from the Contractor's License Law for the
following mason. (Second ]11]1.5, Business and Pmfcssiuns Code: Any city or county
which milaires a permit to construct, alcor, improve, Jemnikh, or repair any structure
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prior In its issuance, also rcyuires the applicant for such Permit to rile a signed statement
that he is licensed pursvanuo the provisions of the Contmom's License Low (Chapter 9
Sq. Ft. Floor Area al atl
(commencing with Section 7") of Division 3 of the Businec and Professions Code) or
that he is exempt therefrom and the basis for Ne alleged exemption. Any violation of
Section 7031.5 by any applicant for a permit subjecu the applicant to a civil penaltyof
ara
Occupancy T
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not more Chad five hundred dollars (SSI%).
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❑ I, a owner of the property, m my employees with wages as Near sole compensation.
will do the work, and Che strumus is not intended or offered for sale (Sec. ](Wq Business
and Professions Code: The Contractors License Law docs not apply to an owner of
Required Inspections
pnperty who builds or improves thereon, and who does such work himsalf or through his
Man employees, provided that such improwmcros an not intended or offered for sale. If.
however, the building or improvement is sold within one year of completion, the owner
builder will have the burden of proving that he did not build Lir improve for purpose of
salt.).
❑ 1. as owner of the progeny, am exclusively Contracting with licensed contractors to
Gonattael the project (Sec. 7044, Business and Professions Codc:) The Contractor's Li
cense taw does not apply to en owner of property who Milds or improves thereon, and
who contracts for such projects with a contraaor(s) licensed pursuant to Che ComeacturY
License Law.
❑ 1 am exempt under Sec. B & P C for this motors
Owner Data
WORKER'S COMPENSATION DECLARATION
I hereby M. under penalty of perjury one of the following decltualmers:
❑ I have and will maintain a Cenificae of Consent to sel6insvm for Worker'sComped-
sation, as provided for by Section 3700 of the Labor Code, for the porromeame of the
work for which this permit is issued.
❑ 1 have and will mainuid Worker's Compensation last once, as MiMmil by Section
3700 of the labor Code, for the pcifofmance of the work for which this permit is issued.
My Worker's Compens tion Insurance carrier and Policy aurWr am:
Cai A m�� :IYCM^'+rgrgoliry No.: I . i
CERTIFICATE OF E%EMPItO f WORKERS'
COMPENSATION INS ANCE
(This section need n A M completed if the permit is fnrome hundred dnllarx (SIM)
,it less.)
1 Certify that in the Perfomunce of the work for which this permit is issued, 1 shall not
employ any person in any manner so as In become subject o the Workers' Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, after making this Cemifieam of Exemption, you should
become Subject to the Worker's Compensation provisions of the Labor Code, you must
forthwith comply with such provisions or this perm it shall he deemed revoked.
CONSTRUCTION LENDING AGENCY
I hereby affirm that them is a construction lending agency for dic performance of
Ne work for which this permit is issued (Sec. UNI, Civ. C.)
Under'a Name
Lender's Address
I certify that 1 have read this application and sham that Ne above infom ilhon is
correct. I agree m comply with all city and county Ord;nancea and sum laws slating to
building construction. and hereby authorize reprcecntativca of this City tu toter upon the
above mentioned property ser inspection purpowhich
ms.
(We) agree m save, indemnify and keep harmtere the City of Cupcnido against
craning expenses may in any way accede against said City
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in of the
n PLIC NT of thegranting of this permit.
Permit.
' URCE T UNDERSTANDS AND WILL COMPLY HALL NON POINT
O UL IONS,
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Issued by: Date
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Re -roofs
-roofs
Signal.. ofXpphcaoVCpmracmr Date
HAZARDOUS MATERIALS DISCLOSURE
Type of Roof
Will the applicant Lir future building Occupant store or handle hazardous material
as defined by the Cupenino Municipal Cade, Chapter 9.13, and the Health and Safety
GWC. Second 25533(a)
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All roofs shall be inspected prior to any roofing material being installed.
Will the aMpdeaM1 IIf
Will the applicant or fetus building occupant use equipment or devices which
an P
a roof is installed without first obtaininginspection, I agree to remove
emit hazardous air Contaminants as defined by the Bay Area Air Quality Management
District?
all new materials for inspection.
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❑Yes 1 ][j Na
1 have read Ne hrnidnm materials reyuimencers under Chapter 6.95 of the Califno-
nix Health &SafctyCale. Suctiotu 25505.35533 and 25534.1 understand ther ifthe Wilding
dons not C remdy have a tenant, that it is my respo sibil4y m notify the n cup rm of do
'
twhi must M mel poor to issuance of a Cmdficas of Occupancy.
Signature of Applicant Date
a—
All roof coverings to be Class "B" or better
oweerorad,nori.etlagedl Dam