02100040 JO"N
TY OF CUPER'1'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION ''
)i&&1L@FS8 BLANEY AV JAMES LI ' S PERMITN(02100040
1I , LI I S APPLICATIJf'�I W4T/2002
E: SANITARY NO. 1 I CONTROL NO.
ARCUITEC(ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECII
wwr LICENSED CONTRACTOR'S DECLARATION bbnn
F 1 nerenr alum mal I am rcensed antic,provisions..r enamen v(commencing REVISION--IN gM12Cr13�T ONLY
i with Smthm70vXgol Division Sill me Business and Professions Code and my license ix
Mfnufoximmi eel. ORIG. #020200075r NO NEW PERMIT ISSUED.
anZ License Class Liao
0n=w Dam Contractor
ARCIIITECI'S DECLARATION
9 K� I understand my Plans shall Is,used as Public records /
�3u.G Licensed Professional
=0OWNEBUILDER DECLARATION
HaY R I wrchy affirm that 1 am exempt from the Contractors License Law lou thc V
o O following.,.,,an.(Section 9031.5.Business and Pr lessionx Code:Any city fir enumy \/
s6s m which requires a permit m construct,alter,improve,Jcmnikh.m repair any structure v $60000
'i1—'^ prior to its issuance.also requires the applicant loarsuch Permil to file a signed statement
fiothat he is licensed Lammamlothe provisions ofthe Contractor's License Law(Chapter 9 Sq. t. Floor Area Valuation
(Commencingwith Section 7000)of Division 3 of the Business and Professions Code)I
a 3§ that he is exempt therefrom andthe basis for the alleged exemption.Any violation of 36923051 . 00
Section 703 1.5 by any applicant for a Permit ubjects the applianno a civil Penally of APN Number Occupancy T
not mom man five hundred dollars($500). 101 - FOUNDATION '
P y Ype
I,as owner of the ProPcrtX or mY emDl%tees with wase as Meir sole compcwtion,
will do the work,and Ne structure is not intended or offered for sale(Sec.'lfe4,Business 3:E)2 PiERS
and Professions Cook:The Contractor's License law does not apply to an owner of 103 - UFER Required Inspections
property who builds or improves thereon,and who does such work himsellar through his
own employees,provided that such improvements are not intended or offered l or sale.If, 104 — REBAR
however.out building or improvement is said within oft year of completion,me owner
builder will fisw the Lamar of proving mat w did not wild or improve for propose of 105 — ANCHOR BOLTS
sa1e'). 106 — SEWER & WATER
❑I.as owner of the property,am exclusively contracting with lianeed contractors to 202 — UNDERFLOOR PLUMBING
conslmcl the project(Sec.9044,Business and Professions Code:)The Contractor's Li-
most Law does nor apply toanowncrof property who Wilds orimprosvmctron,and. 203 — UNDERFLOOR MECHANICAL
1.«nse Law. for such projccuwith antmranm(slJicen.¢d porsummmthe Conuamor's 204 — UNDERFLOOR FRAME
I am exempt under Sm. B&PCfor this maaan 205 — UNDERFLOOR INSULATION
fief Date 301 — ROUGH PLUMBING
WORKER'S COMPENSATION DECLARATION 302 - TUB & OR SHOWER
I hereby air.ander pcnahy of pe pa,one of the fouowing declarations: 303 — ROUGH MECHANICAL
I have and will maintain a Certificate of Consent self-insure for Worker's Compen-
13700
nn.as Provided for by Seeman 37W of the law,Code for the performance of the 3 04 — ROUGH ELECTRICAL
k for which this permit is issued. 3 05 — FRAME
1 have and will maintain Workers Compensation Lawrence,as required by Section 306 — HOEDOWNS
of the labor Code,for the performance of the work for which this Permit is issued.Workers Compensation Insurance carrier and Policy number am: 307 - INSULATION
Carrier. Policy No, 308 - SHEETROCK
CERTIFICATECOMPENSATION INSURANCE 1ON FROM ORKERS'
309 — EXTERIOR LATH
(Thissectionneed nmwcnmplemd ifthe pomitisforone hundreddollars($Rgq 310 — INTERIOR LATH
O11Cei) 311 — SCRATCH COAT
I cenify that in the Performance of the work for which this Permit is issued.1 shall not 313 - ROOF NAIL
employ any person in any manner art as ao wm
mme subject to the Workers Copensation
Laws orCalifornia.Date
Applicant 501 - FINAL ELECTRICAL ENERGY
NOTICE TO APPLICANT:If.after making this Cenificamul Exentaina,you should 502 - FINAL PLUMBING ENERGY
become subject to the worker'sCompensation provisions of thclaMU Code you must 503 — FINAL MECHANICAL ENERGY
OZ become sunmplywith such It rkera Comns or ensatispprmisions whecmkired Codcd.
Z 0 CONSTRUCTION LENDING AGENCY 504 — FINAL BUILDING ENERGY
N IM1erebyxBomthatmcrcisacommotion lending agency fathe perbomanceof 505 — FINAL ELECTRICAL
L.L' >
'he work fill which this permit isheard(See.l(Y19.CimC)
Under'a Name 506 - GAS TEST
W `n
7 Z Isndcr'sAedress 507 — FINAL PLUMBING
U 0 1 certify Real 1 have mad this application and some that the above information is 508 — FINAL MECHANICAL
W F correct.l agree to core ply with all city and county ordinances andxente laws relating to
0U wildingconswction.and hereby authorize mpresenmtiverofNiscity toenter upon the 5 FINAL GRADE
r W above mentioned property for inspection purposes 10 F I N
D. (We)agree to save.moment fy and keep harmless the City of Cupcnia.against G
H h
Liabilities,judgments.costs and expenses which may in any way acerae against said City 5 N LI WORKS /
V Z In con.,trance of the gramm,of this permit LI/
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE REGULATIONS.
Re-roofs
Signature of ApplicaHAZARDOUS
AZAR O Date
IIAZARDOU SMdo,nev MATERIALS URE Type of Roof
Will the applicant o furore building e,Chapter
mom m handle Health an material
dc.Sec io me Cupcnino Municipal GWc.Chapter 9.12,and the Health and Salmy
c,S 25532(0)!
❑Yr, E]No All roofs shall be inspected prior to any roofing material being installed.
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I agree to remove
cm it hazardous air commitments as defirad by the Bay Arca Air Quality Management all new materials for inspection.
District'
❑Yes ❑No
I have read the houthd us materials requirements their Chapter b 95 of the Cali for
ilia Bcallh&Safety Code.Sections 25515,25533 and 25534.1 undersand Nat ifthe wilding
dons not currently have a tenant,that it is my resporoibility,to notify Be occupant of the
requirements which must ho met prior to mattes of a cenirae ofocupancy. Signature of Applicant Date
owner or authorized agent Da,e All roof coverings to be Class "B"or better