00080222 CITY OF'CUPER'fINO -
BUILDING DIVISION ' ` ' PERMIT CONTRACTOR INFORMATION: . ,
'NWILDING ADDRF.SS: - ' ' • PERMIT NO.
h )WNER'SNAMF' 3 - APPLICATIONS' 222 '
(}@E:. CREW. A _ , or SANII'AIWNFI `�
t 999P
,s p 1 ,
O z z ARCHITECT/F.NGINFFR BUILDING PERM11'INFO
at O Fla , LDG ELECT PLUMB MUCH
F z w .
m«
mZ
.iLICbhSEDla CONTRACTOR'S d... DECLARA910N ,
o�yo e ,'7, yanfothat l r :a d p proof Chapter 9Chnn. x . lob Desenphon " .. .- .
1.. Z4 winsf 7000)of Sof he land Profess nCJtrdngl'
fail Rd offied,
�K ¢ License Class "T LCR ' ( -
a°�� Dale e ttetn� WATER 'HEATER
F a - , ARCHITECT'S DECLARATION
1 prolenarnad- y PI ::hall be nwd us public enures k
uh el 2 Lc J P f: I '
OWNER BUILDER DECLARATION
1 hembor thri Its,loverall,f
Business
h t e Coal ael I c ry f tit
zj< fell g h (Station 7031,5,ct d 1 f :Chile A y pstructure re
EZO p iryu' pe tri construct, II p d I'I rtp.irnry stt emre -
'�3� pion t L 1 :Ih 'ky'n' It hp. -'n II La 7,.l rant I .
mml JP n thep fth t I t f L rill Choral,9 Sg: Ft. Floor Area - _ duan
or
g ro Section 9oWl 1D' 3 nn ❑ : J P I :: : oda) _ + i
. or that he is exempi lh iron and Jehnvs for me alle&esLexemption.AnY violation ^ _, .. -. - <
of Section 70315 by'iyappfaam for up nar bids the appl' nh u dvil venahv _
.arnor m,ro mat fie ioadrea dollars($500). - - 'APN Number - Occup
i
' ❑I,as owner of me l � v,
pmper y,or my employeex with,wugns es Meir sole compenealinn,
.
will do Ole work, J t t ct - tintended B d r r I 1s 7044 . .'32641.04 O �9Inspections, -
Bu .. and 1 fd Chile Ih C t t -:L La d I apply I - Rm Vlred
vl�sprr.f properly
Who wild, p Ih d 1 a n' k himself
' elf
or 1r xhhwitemployees,p 'd that h_ 1 I n:am Iintended r
nI .ir however, he 6ve w ,n' eyear r
moapicti y the awnlhtatetl Itrdenproving,x mal he 7,a not nla or
502k FINAL PLUMBING ENERGY
prodafrvnpoamame.>
506 — GAS 'TEST
111,its owner of the pro,stoy.air xil :'vely contracting with 1 sensed contract .. 507• —, FINAL PLUMBING
L,nsbncl me project(see:7044,Business d Pormst'n s Cnde')Tile Cocmr s
icense Law does not apply to an owner orpropeny win builds or improves thereon,
,and woe contuc¢,for such projects with a conn eters) liceiuee purmaiu to the
Contractors License Law. -
❑lamexemptunderSec. ,❑&P C for lois rcarnn
,. Owner h Date -
e.I WORKER'S COMPENSATION DECLARATION -
I hereby notion under penally el penalty oneof Inc ratio wing declaration -
I have and will briatchn a Certificate 1Consent to jeff,aspire" f Worker',
Co p f as provided' I r by Se 3700 of the U h C da,.fn the -
perlarmmee of the work for whish hill,permit is iswed. s -
°1 have unit will molar:..Workur's CohnlRtrsalinn Insnranac,as required by Section ' - -
4
,37(10 of the Labor Code,ba.IAe pedorinunaesor the work for which this permit is, -
ft
issued,My Worker's C 1 :'I asuminceclrricr ontl Pol c,uppribir oto
-
Carrier:- - Palmy No.: -
CPRTIPICAI ION OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE, ' , LI '
r (I tit, notion need not be complete)tf the perm Is for one hundred dollar,
15100)orless.) - ,
I certify that In the performmce of the work for which this permit is Issued,I _
_shall nm employ any pemut is any mummr sit us to become omem u,the Workers "
Compensation Laws of California Date „
'Appiicnm - •• - -
NOLCETOAPPILCANTI! Il k gm C ulmm rE etpl' y hound _
hen te: 63.tt JaW k C p :m ,lolvilion,ofit Labor Coca,yon null t
ZQ
forthwith cripplY with aph provitions or this perinit shall bdepped- ked - - '" Alf
-
v I CONSTRUCTIONIFNDING AGENCY
a I hereby affirai that there 'I a' leading axe y for the pervabil nce _
ords,so ,fit,whichlh Peru,,1;"'all[(S3097,Cr,,C c - ,J`" - ,I..
h 1 Q Lend shame . i
1 IfytbtlInner,paid this' 'ppI' t and state that tiabove prat' ,
carr I I g t Ily -tit II city J ty 1d ,hod share law,
t..) lith Id' 8 t (on,andhereby authari7e path l( - it his city it)enter upon
Inc h
(W)agc I s d ty dk p1 nl 0 City fCpn' against
,-
h Ilan l l c' pulgarent,,'crols and expenses which Fory in any way' nganot said
6,) z City,a sposteReack ,file treating of this penal,
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT' y
'. Date
SOURCE REGULATIONS.'.. �, Issued b +' t r '
Signature of Applicant/Commalnr Date "' . ' -. -
HAZARDOUS MATERIALS DISCLOSURE "r s, .Re-rOOFS ? e r(' ,' t
Will me appl ve I f t building occupant store or n eI h tel material Type of;Roof'< -
as dc1 ncd by the Cupert hit Mun'c'p II Cn(lc,Chapter 9 13 and the Health and Safety
Code,S-climh 2553204)7
°v" - El No, n
t Alfroofs:ditm "s'hall m
be. spected prior to any-roofing material being Installed'.
Will t ppf, I triple n 'lag d' t yoip rJ a which ,If a roof isinstalled without first obitiming an inspection, 1 agree to remove
plot ha/ad , ircnm t: dhyll Bill cloudy Minanenenl _
ial t ., , `all new materials forinspection„ Applicant understands and will comply.with
Cas °no" �- all non-.point source regulations:•
Ih - nithefarenJo.,faciamls ectioneopent.,' ionic,Chapter 6 95 ifm's t * -
- Clif 'aHrltiffiSfely Code,Scwinns2550525533 the 55341 1 :l Ithr a - " - of - I
ifth b 'Idngl I Ily hs aha tlht'ti ntyresponsibility t Yfylho I • .
tttpnl of 11 prr t:which nustb tlr ntosn fa Cerileal f a' _ "
Decrepitly.' 'Signature of Applieanl, " - - Dateld�l " a "
. l] bocovngSown aulmiday t D� s or better.