05040173 CITY OF CUPEWI'INO
BUILDING DlvlsloN PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: PERMIT NO.
COUTTOLENC NEFTE 05040173
OWNER'S NAME: PERMITISSUEDATE
E:
Nt
SANITARY NO. OL NO.
ARCHIILCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
LOo LICENSED CONTRACTOR'S DECLARATION
p I hereby affum x4411 am littmed umkr provisions nfCbepmr 9 fcrd me.soj Job Description
�6y wibS.tion7").fDivision 3ofleflow rsayld ProJguinnsCO,�myliccnscix
P m in full force. Heeler VYJ 1S
j(az Llunseclaxy�_.�!/O/2REVISION- -CHG SLID. DOOR TO WINDOW (3)
�c""DISO NO NEW PERMIT ISSUED/ORIG. 404110147
qq Cll Ne.sSDECLARATION
�i a Q 1 and nunJ y plans shell he uscJ as poetic records
J U
3 a Licensed Pm(cssinnal
a'DS
OWNER-BUILDER
mptfl.Ce C.... ..
1 hereby affirm ten I em exempt,rum the Conons Co esterase Law for the
p 0 wllnwing oba is permit t no s.;ct,at.[s and P .fieri m Code:Any city or county
which myuimx a permit In construct,.1¢r,improve,demolish,or repair an,alrucwm
Fiy
poor n its issuance,mist)requires the applicant for such Permit o file a signed statement
££xxao that he is licensed punuanlinthe provisions OFthe Contractor's License Law(Chapter Y Sq.Ft.Floor Area Valuat10 115
yF (commencing with Section NMM)Of Division 3 of the B usincu and Profcsainm Code)or
y $
that he is exempt therefrom and she basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a forest subjects the applicant o a civil penally of APN Number Occupancy Type
not more than fes hundred della.(8500).
❑I,asownm close property,Or myemploycu with wagemas dreirseleeompenullon, 37518016 . 00
will do Nc work.and the awnurt is nm inmMcO oroffercd forss1,(See.7044.Business
and Professions Code:The Conuacmr's Liceue Law does Imo apply to an owner of Required Inspections
property who builds or improves thereon,and whodoes such work himselfor through his
own mployees,provided that such improvements are not intended of offered(or sale.If.
however,the building or improvement is sold within ON year of completion,she owner.
builder will have the burden of proving that M did not Wild or improve for purpose of
sal..).
❑I,a owner of ct SeeProperty,.B exclusivelynesad contracting with:)The Cconuacm, i
censwn the project(Sec.i nan Business and Professions ds or i pro Conhumri rad
marc nab Cos not apply je an owner of property who Wilds or improves thereon,and
who connects for[ucA projects with a eomranor(q licenced pursuant to the Contractors
License Law.
I em exempt under Sec. .B h P C for this_coon
Ownerlit Data
WORKER'S COMPENSATION DECLARATION
1 Mmby a?mr under penalty of perjury one of the following dulunions:
I have and will maintain a Certificate of Consent to mir-whim,for Worker'aC"mpen-
sation,as provided for by Section 37M of the labor Code.for the performance of the
work for which Nis pend Ii is issued.
1 have and will maintain Worker's Compensation Insurance,M required by Section
37M of the Ube,Code,for Ne penfoomance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier'. Policy No.:
CERTIFICATE OF EX Ead MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecompleedift a pens Isforenchundreddollen(8100)
or less.)
1 ccnify that in the Perftnmance of the work for which this per 'i Is iss a I.I shall not
employ any'penden in any manner sn 5t haW esu ' tot /_firs: mrmastion
Laws of California.Data
O
Applicant
NOTICE TO APPLICANT:IL after mating this Ceilirgric of4Exanine youyou shmusoulds
become suhjum
l to the Worker's Copnt
cnion pn
rest Of IN _Cndc,
,JZ forthwith comply with such pmvisinmmlhia permit all Wdk edrtvoked.
Z O CONSTRUCTION LENDING AGEN
�-. 1 hereby affrm than there is a construction lending agency for the performanu of
0,> the work for which this parmR Is issued(sec.3007.civ.C.)
W D Lenders Name
O. Lenders Address
rJ p1 ccnify that 1 have read this application and ewe that the above Information is
F room.l agree to comply with all city and county undines and cute laws reprint e
C)
U above-mentioned
hereby amhonp rposes. lives of this city mcmer upon the
ahnvo(We) ncd pmperty,for inspection purposes. () �
G (We)egret t Pave,indemnify and tech harmless the City n(ca amino against
E"v7 75�:
Iiebilitiu,judeid shoats and cxpcnavcs which may in any way accroc against said City / r'
U Z, APPLICANT/CO DEReis permit.
STAn DSIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE Rt LAT N
6 Re-roofs
Sip' wenn One
T.i.c
ftDOUS MATERIALS DI CLOSURE Type of Roof
Nc fuwrc building oceupentsmrc nr Mndlc hevudous materialt d by t c Cu Municipal Code.Chapter 9.12,and the Health and Safety
owe.Seetion 5532 All roofs shall be inspected prior to any roofing material being installed.
/oyes /1"Nu
�-- Will the applicmm or future Wdi ingmcupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haasrdnus air contaminants as defined by the Bay Area Air Quality Management all new a r inspection.
District?
❑Yam Nn
I have mad tyetiaaaN us materials mquiremcnu under Chapter 6.95 ofWCalifon-
mail IN g:Safe .sec" 15505.25533and2553a.lundemam NnifNe Wilding
J.not coraco hive a ten. Nat it is my mapmnihility w nu"fy the occupant of N.
require nts e I Ipdofmissanne.,.een0e ." ary. Signature ofApplical Date
2 ® S� All roof coverings to be Class"B"or better
247hmidd ag Date
CITY OF CUPEWI'INO
BUILDING DlvlsloN PERMIT CONTRACTOR INFORMATION.
BUILDING ADDRESS: PERMIT NO.
COUTTOLENC NEFTE 05040173
OWNER'S NAME: PERMITISSUEDATE
E:
Nt
SANITARY NO. OL NO.
ARCHIILCT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MPRH
LOo LICENSED CONTRACTOR'S DECLARATION
p I hereby affum x4411 am littmed umkr provisions nfCbepmr 9 fcrd me.soj Job Description
�6y wibS.tion7").fDivision 3ofleflow rsayld ProJguinnsCO,�myliccnscix
P m in full force. Heeler VYJ 1S
j(az Llunseclaxy�_.�!/O/2REVISION- -CHG SLID. DOOR TO WINDOW (3)
�c""DISO NO NEW PERMIT ISSUED/ORIG. 404110147
qq Cll Ne.sSDECLARATION
�i a Q 1 and nunJ y plans shell he uscJ as poetic records
J U
3 a Licensed Pm(cssinnal
a'DS
OWNER-BUILDER
mptfl.Ce C.... ..
1 hereby affirm ten I em exempt,rum the Conons Co esterase Law for the
p 0 wllnwing oba is permit t no s.;ct,at.[s and P .fieri m Code:Any city or county
which myuimx a permit In construct,.1¢r,improve,demolish,or repair an,alrucwm
Fiy
poor n its issuance,mist)requires the applicant for such Permit o file a signed statement
££xxao that he is licensed punuanlinthe provisions OFthe Contractor's License Law(Chapter Y Sq.Ft.Floor Area Valuat10 115
yF (commencing with Section NMM)Of Division 3 of the B usincu and Profcsainm Code)or
y $
that he is exempt therefrom and she basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a forest subjects the applicant o a civil penally of APN Number Occupancy Type
not more than fes hundred della.(8500).
❑I,asownm close property,Or myemploycu with wagemas dreirseleeompenullon, 37518016 . 00
will do Nc work.and the awnurt is nm inmMcO oroffercd forss1,(See.7044.Business
and Professions Code:The Conuacmr's Liceue Law does Imo apply to an owner of Required Inspections
property who builds or improves thereon,and whodoes such work himselfor through his
own mployees,provided that such improvements are not intended of offered(or sale.If.
however,the building or improvement is sold within ON year of completion,she owner.
builder will have the burden of proving that M did not Wild or improve for purpose of
sal..).
❑I,a owner of ct SeeProperty,.B exclusivelynesad contracting with:)The Cconuacm, i
censwn the project(Sec.i nan Business and Professions ds or i pro Conhumri rad
marc nab Cos not apply je an owner of property who Wilds or improves thereon,and
who connects for[ucA projects with a eomranor(q licenced pursuant to the Contractors
License Law.
I em exempt under Sec. .B h P C for this_coon
Ownerlit Data
WORKER'S COMPENSATION DECLARATION
1 Mmby a?mr under penalty of perjury one of the following dulunions:
I have and will maintain a Certificate of Consent to mir-whim,for Worker'aC"mpen-
sation,as provided for by Section 37M of the labor Code.for the performance of the
work for which Nis pend Ii is issued.
1 have and will maintain Worker's Compensation Insurance,M required by Section
37M of the Ube,Code,for Ne penfoomance of Ne work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number am:
Cartier'. Policy No.:
CERTIFICATE OF EX Ead MON FROM WORKERS'
COMPENSATION INSURANCE
(This section need not hecompleedift a pens Isforenchundreddollen(8100)
or less.)
1 ccnify that in the Perftnmance of the work for which this per 'i Is iss a I.I shall not
employ any'penden in any manner sn 5t haW esu ' tot /_firs: mrmastion
Laws of California.Data
O
Applicant
NOTICE TO APPLICANT:IL after mating this Ceilirgric of4Exanine youyou shmusoulds
become suhjum
l to the Worker's Copnt
cnion pn
rest Of IN _Cndc,
,JZ forthwith comply with such pmvisinmmlhia permit all Wdk edrtvoked.
Z O CONSTRUCTION LENDING AGEN
�-. 1 hereby affrm than there is a construction lending agency for the performanu of
0,> the work for which this parmR Is issued(sec.3007.civ.C.)
W D Lenders Name
O. Lenders Address
rJ p1 ccnify that 1 have read this application and ewe that the above Information is
F room.l agree to comply with all city and county undines and cute laws reprint e
C)
U above-mentioned
hereby amhonp rposes. lives of this city mcmer upon the
ahnvo(We) ncd pmperty,for inspection purposes. () �
G (We)egret t Pave,indemnify and tech harmless the City n(ca amino against
E"v7 75�:
Iiebilitiu,judeid shoats and cxpcnavcs which may in any way accroc against said City / r'
U Z, APPLICANT/CO DEReis permit.
STAn DSIAND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE Rt LAT N
6 Re-roofs
Sip' wenn One
T.i.c
ftDOUS MATERIALS DI CLOSURE Type of Roof
Nc fuwrc building oceupentsmrc nr Mndlc hevudous materialt d by t c Cu Municipal Code.Chapter 9.12,and the Health and Safety
owe.Seetion 5532 All roofs shall be inspected prior to any roofing material being installed.
/oyes /1"Nu
�-- Will the applicmm or future Wdi ingmcupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit haasrdnus air contaminants as defined by the Bay Area Air Quality Management all new a r inspection.
District?
❑Yam Nn
I have mad tyetiaaaN us materials mquiremcnu under Chapter 6.95 ofWCalifon-
mail IN g:Safe .sec" 15505.25533and2553a.lundemam NnifNe Wilding
J.not coraco hive a ten. Nat it is my mapmnihility w nu"fy the occupant of N.
require nts e I Ipdofmissanne.,.een0e ." ary. Signature ofApplical Date
2 ® S� All roof coverings to be Class"B"or better
247hmidd ag Date