04110123 CITY OF CUP
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BUILDING DlvlsloN PERMIT ''CONTRACTOR INFORMATIQN `: -
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BuIIDING ADDRESS: W Aum FARNHAM CONSTRUCTION FMMIIND04110123
1053 CAMINO VISTA T)R
OWNER'S NAME: PERMIT ISSUE DATE
FRANK CURTIS W AN _
NE:
SANITARY N0, CONTROL NO.
(408) 378-8522
7in
HITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB- MECH
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uLICENSED CONTRACTOR'S DECLARATIONJob Oestri tlQn
I\Mmbaffirm thatI am I ourdunderpro uiousofChapter9( .ancing 19ec pnf Divixian Sof NC BusmnaanThofessinns Cod end license isra ser L ✓�SS�� 7 REVISION--AADD FOOTING/
e lair 1 I Lit.N
=� ;4f�cnntr NO NEW PERMIT ISSUED/ ORIG. #04060044
r�Li L-10416W ARCHITI�cls c o R"` c DN
;u. Licensed Professional
3 OWNER-BUILDER DECLARATION
1 hereby affirm that I Am cxcmpt from dr Contractor's License Law I'm the
20 following mason.(Section 7031.5,Biomass and Rofessiur.CWC:Any city or county
x n(Li which myuims A Permit a courtroom.alar,I.Pmw,demolish,or repair any structure
u—" prior to its issuanee.alsu squirutM applicant for such permiuo file A signed srrmem
ts'< theMisliccnwdp...intothe pmvisiortsofthe Consumer.License Law(Chapter 9 Sq. Ft.Floor Area Valuatia$t115 - - -
�~$ (commencing with Section 7001 of Division 3 of the Business and Professions Court)or
—
that he a uempr u¢mfrom and Ne'suis for tM alleged exemption.Any violation of
Section 7031.5 by any applicator for A permit subjects the applicant to A civil penally of APN Number Occupancy Type
not mom than Ow hundred doll..(5500).
❑I.u owner of the proprny,or ter cmploym with wages u the'v sole eompensauan. 34214084 . 00
will do Ne work and fee machine is not intended oro@rad for sale(Sm.704.,Business -
And Professions Code:The Contractor's License raw does oat Apply a An owner or - - Required Inspections _.
propeny who builds or improwts unman,and who does such.,it himself on utraugh his
own employees,provided that such improvements art not intended o,offered fmsak.If.
however.the building or improwment is sold withinone year of completion.daowxr-
builder will haw Um burden of proving that he did not Wild or improw for purprvc of
sada.).
I,as Owner of Ble propeny.am exclu holy contracting with Demand con racto.to
consumer the project(Sec.7044.Business and Pmfusimss Cade:)The Contruam s Li.
come Law does not apply to an owner of progeny who builds or improves Eamon,and.
who contacts for such pmjaca wiN a contrumr(s)licensed pursuant to the Contractors _ - - -------'--""' 1�--License Law. V•S� -
❑IameaemplunderSec. ,B&PCforthisretie.
In, -D..-
WORKER
..WORKER'S COMPENSATION DECLARATION
1 hereby affirm under pointy of perjury otic of the following declarations:
have and will maintain a Certificate of Common a self-iuum for Worker'sCompen-
n,u provided for by Section 3700 of Nc lather Code,far Ne performance of the for which this permit is issued.
haw Audi will maintain Workers Compensation Inw.nce,.required by Section
gIt&labor Code,fo the perlormantt of the work for which Nis pamtit is iuued.
W r CnmPensauoyps�nne�Cartier and Policy nmbalAm
ter /1 Polity No. SXL_
CERTIFICATE OF EXEMPI'iQN FRO WORKERS'
COMPENSATIONdI RANCE
(tris action nccJ nor M complerJ if rM permit is foram hundmd dollars(51011)
or Ices.)
1 ccnifv thus in Nc Performance of Ne work for which this permit is issued,l shall not
employ any person in any manner an As in become subject to Ne WorkersCompensation
Laws of California.Data
Applicant
NOTICE TO APPLICANT:If,after making this Certificate of Exemption,you should
become subject m Ne Worker's Compemaunn previsions of the IoM,Code,you must
z forthwith comply with such prnvainna or Nis permit shall M deemed naked.
z"
CONSTRUCTION LENDING AGENCY
Ihemby.Rrm that Nem is a construction lending agency for we perf orwoce of
CL the.,it for which this permit is issued(Sec.3097,Civ.C.)
la1 lenders Namc
C Lender's Address
z ��—
U O 1 aNfy that I haw mad this application And sure that the above information u
IL F cmrecr.1 agree to comply with all city and county ordinances and sate laws relating to
�(J building construction,and hereby addmice uaPwAmogM of this City to Curr upon the
a�"ta .1ww-mactiORd property for Inspection proposes.
(We).,me rat saw,indemnify and keep harmless the City or Cupenina against I
Hten Iiabiliucajudgmenb,cous andcapcnses which mryinany wayaccsue agaiutuid City /
V Z in consequence of the granting of this Permit.
r
NT UNDERSTA S ND WILL COMPLY WITH ALL NON-POINT Issuedby: Date
LATO _ ��P'GSRe-roofsf ApPlic HACZOARDOUS MATERIALS DISCL SURE tor 1, DarType of Roof
l the applicant ser future building Occupant atom or handle havudous material
by the Cupenum Municipal Code.Chapter 9.12,and d e Health and Safety
ea zss3z(a)? All roofs shall be inspected prior to any roofing material being installed.
ca 1Al(u the mi lb.nt or futtu`re building occupant use equipment or devices whichIf a roof is installed without first obtaining an inspection,I agree to remove
dous air contaminants As defined by the Bay Area Air Quality Management all new materials for inspection.
p Yes [ Aa
1 have mail the huardousmaterials requirements under Chamer695 of the Calirm.
iia Health& ctyCode,Secuou255M,25533 and 25534.1 understand than ifthc Wilding
Jan of cu ndyu h Pz they respomihilitY a nouly the occupant of the
requi>�mc h np at cofaccnirmamor Y. Signature ofApplicant
Date
�� D� All roof coverings to be Class"B" or better
Owner or authomcil agent Date