03090064OF CUPER"I'INO
$'� �r�:.si
BUILDING DIVISION PERMIT
,CONTRACTnRfINF0RMATION�p,6!
Fc,rry
,DING ADDRESS:
J. M. O'NEILL, INC
PERMIT NOU 3090064
ER'S NAME:
PERMIT ISSUE DATE
TERO (REAL ESTATE
58 W.
3
NE:
IRCHITE-CTIENGINEER:
SANITARY NO. CONTROL NO.
(925)225-1200
BUILDING PERMIT INFO
BLDG ELECT PLUMP MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
9
Job Description
1 hereby that 1 am underprovisions of Chapter ((commencing
with Saction700)olDiviaonJofrW B%xcsand PmfccsmC.da,andmylccnsc is
a)rTmcm
In ran mRa
44'(0i2>
REVISION -IN HOUSE USE ONLY
Liconao C n
Da 2 — Guolr ter ur-y
NO NEW PERMIT ISSUED, ORIG.#03040064
RATION
ARC1fITELTs �LARATION
1 understand my plans shall W used as public records
Licensed Professional
OWNER BUILDER DECLARATION
1 hereby affirm that I am exempt from the Contractors License Law for the
following reffmo. (Section 7031.5. Business and Profcssiva Code: Any city or county
which requires a permit to construct, alter, improve, demolish, or repair any .mmetum
prior to its issuance, also mgvires the applicant for such permit a Elea eigacd amtem ut
that he is Rcanecd pursuant to the provisions of the contractors License Law (Chapter 9
Sq. Ft. Floor Area
Valuation $0
(cum mending with Section 70110) of Division 3 of the Business and Professions Calc) or
Nat he is exempt mcmfrom and IM hasis for the alleged exemption. Any viohomn of
APN Number
- Occupancy Type
Section 7031.5 by any applicant for a Permit subjects the applicant to a civil penalty of
not more man Eve hundred donors (SSW).
3 2633103.00 '
❑ I, az owner of the propeary. of my employees with wagesaz their sole commensalion.
Required Inspections
will du me work, and the structure is not intended or offered for sale (See. 70,4, Business
and Professions Coda: The Comnctor'a License law does oat apply to an he, of
property who builds or improves thereon, and who does such work himself or through his
Own employ.,provided that such impowco nu Lie not intended proffered for sale. If.
however, me building or improvement is said within one yea of completion, the owner.
builder will have the burden of proving mat he did not Wild or on prove for purpose of
sale.).
❑ 1. as owner of me property, am exclusively contacting with licensed convectors m
construct tM project yet. TNA. Business and Professions Code.) The Conuacmr's U.
Tense law tlme not apply toa an owner of prnPeny who rs improves and
Condition's
whocontractsLacu for such pmjecu with a conuanor(x) licensed pursuant tie Canuactar's
sed p
License law.
❑ 1 m aexempt under Sec, . B & P C for this reason
Date
WORKER'S COMPENSATION DECLARATION
hereby eRnn under Penalty of pe jury one of the following decimations:
ifcc of Consent m self -insure for Workers Camper.
1 have and will maintain a Cena
smon, as provided for by Section 37W 0( the Labor code, rnr the perrmmanac of the
work for which this Permit is issued.
0 1 have and will maintain Workers Cpmpensmmd Insurance, az required by Section
3700 of the labor Code. for he p admin ancc of the work for which this permit is issued.
My Worker's Compensation Insuranea carrier and Policy number art:
rr; r:sE 'F...�-,.rte fbi(dy Nn.:1'14�1 S3 22
CERTIFICATE OF E%EM MON FROM WORK ERS'
COMPENSATIlrN INSURANCE
mos section need not W eomPlelod irthe Permit is mount, hundred dictator ($100)
less.
1 cml fy mat in the pmrromearce of the work for which this permit is issued, I shall not
employ any Perron i n any manner so az to become subject In the Workers Compensation
.
Laws of California. Data
AppEcam
NOTICE TO APPLICANT: IL after making this CcNfinte of Eacmption. you should
become suhject to the Worker's Compensmion previsions of the labor Code, you must
forthwith comply with such provisions of this Permit shall he deemed revalued.
CONSTRUCTION LENDING AGENCY
1 hemby affirm that dere is a construction lending agency for tW performance Of
Ne work for which his permit is issued (Scc. 3097, Civ, C.)
Lender's Name
Lenders Address
1 codify that I have read this application and sum that the above inromtaiun is
torte". 1 agree to comply with all city and county oNinanees and state laws relating to
building construction. and hereby aummuc mpracntarives of this city to enter upon the
above-mentimKd property (or Inspection pmpn5ei.
(We) agree to save, indcmmfy and keep hannleas the City of Cuycnino against
Eiabilitics,judgmcnu. case and ax,enus which may in any way accmc against said City
ueoce of the Ba ing of a ram
LIC NT UN T D AN WILL COMPLY WITH ALL NON -POINT
Issued by: Date
RC I _
1�6
-`�4'
e-roofsa
Type of Roof
u a of ApplicanVComranar Doc
HAZARDOUS MATERIALS DISCLOSURE
Will the applicant or future building Occupant store or handle hv4Nuus material
;Di,fricL?
fined by the Cimarron Municipal Code. Chapter 9.13, and the Hcahh and Safety
Section z5532(a)p
XNaP
All roofs shall be ins ected rior to an roofin material bein❑Yea
P Y g g installed.
If a roof is installed without first obtaining an inspection, I agree to remove
will thea fiaant or comm buudin
Pp s occupant use
or devises whimhvnrdnus
air mnmminants az defncd by the Bay Arca Air Quality Managcmcnt
. At,Qa
all new materials for inspection.
�
❑Yes 4 4
1 have mad me h=Wglus mucrials mquimmenu un kr Chaper 695 of the Califor-
niaHd thG Safcty QMc. Sccuorts]55f15.35533 and 2553d.l undcrsund thaif the Wilding
I not tiredly
icd ly have Nat i - respamibility to noufy the occupant of me
rt 'rem Its - t 'o miss...I. Ccraficide.f cup y_
(�
Signature of Applicant Date
All roof coverings to be Class "B" or better
1
cr ar amhoriacd ag"m Dam