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CITY OF CUPEWrINO
BUILDING DIVISION PERMIT
WCONTRAC,TORINFORMATIQNN .
BUIL DING ADDRESS:
N DE AN17A PI 17D 4 G)
NOVO CONSTRUCTION
PERMRN$5020093
R'S NAME:
PERMIT ISSUE DATE
E:
SANITARY NO, CONTROL NO.
i:i(650)701-1900
ARCHITECT/ENGINEER:
BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
LICENSED CONTRACTOR'S DECLARATION
Jb Description
o
pter 9 mencing
1 hcmby affirm that 1 am licensed under provisions of Cha(com
with Section 9000) of Division 3 of the Businea and Professions Code, and my license is
tuit F
Intorte and cBem
in ,879/Ozz
REVISION --IN HOUSE USE ONLY
LiceI Class Lk. •
On Couabmr
NO NEW PERMIT ISSUED/ORIG. #05010056
ARCHITECTS DECLARATION
I undcrsund my plans shall he used as public memils
Licensed Professional
OWNER -BUILDER DECLARATION
1 hereby affirm Nm I am exempt from the Cmuaaoh License Law for the
following mason. (Section 7031.5, Business and Profeassiolu Cade: Any city or county
which mquirrs a permit to construct, alter, improve, demolish, or .,air any structure
prior m its IyvanR, alas, miotic{ ft appllCanl for Such Permit or Illc a ifi,.d.une r e.,
shat he is liccnscd poorest to din proven. of the Conuactors limns La. (Chip. 9
Sq. Ft. Floor Area
Valuatior$35
(commencing wit Section ]000) of Division 3 of the Business and Professiom Code) or
]has he is except thcmfrom and the basis for din alleged exemption. Any violation of
APN Number
Occupancy Type
p y yp
Section 7031.5 by I, applicant for. permit subjects the applicant to is civil penalty of
not more Nan five hundred dollars (5500.
32633113.00
0 I, as owner of the pmpeny, or my employees with wages as ]heir sole compensation,
will do the work, and the swclum is nal intended m oRemd forsale (Sec. 7064, Business
Required Inspections
and Pmfessiom Codc: TW Conuaclors License Law docs not apply W an owner of
progeny who builds orimproves dxmon, and whodunit uch workhimself ar through his
own employers, provided Net such improvements am not intended oro0ered forsalm. IL
however, the Wilding or improvement is sold within ane year of completion. the owner-
A
builder will have the Womb of proving that he did not Wild or improve for purpose of
sain
❑ I, as tweet of am ane s contracting with licensed mnlncmrs
'
ct See70property.
Business and Professions Code:) The Con t.
construct the project (Sec. and
\
amoun, nd
o an ofpmpeny who Wilds or imp rove theman,and
cense Tawdoes not apply tom
whocontractsLacs for such projects wide a conmnar(x) licensed pursuant to the Conuecmr's
with
LicenseLaw.
❑lam exempt under See ,B&PC for this ..on
ner Date
WORK ER'S COMPENSATION DECLARATION
1 hereby arm under penalty of perjury one of the following declarations:
I have and will maintain a Cenifieme of Consent o self -insure for Worker'sCrimper-
aiiaz pmvidcd for by Scniun 3900 0( do, labor Codc, for the pcsfosmancc of the
work for which this permit is issued. .
d by ction
❑ 1 have and will maintain Workcri Compensation Insurance az lequimSe
3100 of Ne labor Code. for Ne performance of the work for which this permit is issued.
My Workcri Compensation less. artier and Policy number are
camcr.Policy Na.: �SZOJ�%'D7
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This section nail not becompleted Bum permit is far tnc hundred dollars(SIM)
or less.)
1 cenifv Nat in use performance of the work far which this permit is issued. I shall nos
employ any person in any mamorso u in Wcome subject to the Workcri Compensation
Laws of California. Date
Applicant
NOTICE TO APPLICANT: If, afxr making this Certificate or Exemption, you should
become subject in the Worker's Compensation provisions of Ne labor Codc. ynu must
foMwlth comply with such provisions or Nis Permit shall W deemed revoked.
CONSTRUCTION LENDING AGENCY
1 hereby affirm that there its construction lending agency Mr the performance of
the work for which this panni, is issued (Sec. 3099, Civ. C.)
Lender's Name
builder's Address
I oenify that l have mad this application and sax that the a Wve information is
colmcL l Agan to comply with all city and county imiw¢es and sate laws mlating to
building coniwnimKrty hereby auWome mprc cnutivss of this city to insect upon Be
ahy
ehovc property for im purposes.
an
indemnity
agree to cavi, indemnify and hmp harmless the City of
(We)a agree against
(s
Iiemiiertucrgmcnh, crisislinumdexpclsscswhich may in anyway eccmc against said City
ju against s
of this
s q
2,/
Aconsequence
APPLICANT UNDERSTANDS ANO WILL COMPLY WITH ALL NON -POINT
UNDERSTANDS WI
J
Issued by: Date
SOUR G A
Re -roofs
Type of Roof
as'
Sigmlure of ApplicanVConlncmr Data
HAZARDOUS MATERIALS DISCLOSURE
Will Bic applicant or future Wilding =upset store or handle hmallous maarial
,
az dc0ned by the Cupenme Municipal Code, Chapter 9.12, and the Health and Safety
otic,Y 5 25532(x)?
All roofs shall be inspected prior to any roofing material being installed.
r ION.
If a roof is installed without first obtaining an inspection, I a ree to remove
g
Will the applicant or future Wilding accupam tau test Tartar dcvims which
II l000dmts air contaminants as defined by the Bay Ama Air Quality Management
all new materials for inspection.
District?
❑Yes 0 N
I have mail the ha>ardous materials requimments under Chapter 6.95 of the Califor.
nia Health& Safety Cale, Sceuons 255)5, 25533 and 25534.1 undersand that ifthe building
does not currently have a ¢pant, that it is my mspomibil by to nobly the occupant of the
mqui my whim must W met prior to issuance of a certificate ortxcurancy.
Signature of Applicant Date
All roof coverings to be Class "B" or better
Wnermaathari>aa
agent Da�