02050009 CITY
DPEISSIIONVOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10500 N DE ANZA BLVD NORTHWEST SIGNS q q 02050009
.THENKIMPTON HOTEL 325 WASHINGTON ST AO5c/T02j2002
rPHONE: (831) 469-8208 SANITARY NO. CONTROL NO.
Mai O ARCHITECGENGINEER: BUILDING PERMIT INFO
g F BLDG ELECT PLUMB MECH
vy a
zI- LICENSED CONTRACTOR'S DECLARATION
Ihereby.fr Nmlamlicensed underprovisionsofChapin,9gommcncing Job Description
1_tw with Sect on]000)olDivision3 oflhe Busine send Professions Cwle.end mylicenu NEW SIGNS
]D a V Lir s Class Li M _
O 40
and NCHITEuse DEGLARATI �
1 un ersmnd my plans sM1all be used as public records
7 o Licensed Professional
OWNER-BUILDER DECLARATION s/tQN .1
1 hereby aRnn that I am exempt from the Contractor's License Law for the ^' 20032500
C?< fallowing mason.(Section 703 I.S.Business and Professions Code:Any city or county
F O wh chrequire,a pem 1 to construct.ulcer, mprme demolish,at t y structure
e3m - poor tOti'suan al q Ih pplcam for such permit filesignednammem . ..._,_"-... _....._..._._ _
tlmhq sl'cenind with Secdal tion
00)of wins nl rhe Contractors and La (Chapter // LL rr r a» D �^ Valuation
Ica me is
i0Sttliot]tjoo) (he basis 3.f the Basin and Pmkssiovi Code? 's t•1�+ 3 L3 ®' � � J(•..Yt T.i t.l.i, / V
or that he is exempt Iany applicant
and the basis for the subjects
th tl ekemant t Any violation
Of Section 7031.5 by any applicam for a permit subjects the applicant m e civil penalty
Lor not more duan five hundred dollars(6500). 101APN �h�AT I ON , Occupancy Type
°1,as owner of the properly,or my employees with wages as their sole compensation, - UFER
-will me the ork.Pod and the rode Theure s mm mended en offered for sale(sec: to an n 104 - REBAR Required Inspections
owner ss'and Professions Cade:The Commnoi s License Law does not apply torn
vwnerugh his ry,ow employeeho s orimprovest me such imdwhodoes to not intended!
lf
or 105_ - ANCHOR BOLTS
or through his own employees.provided that such improvcmrnrs arc not intended or
-complleinr.me.IL-hawever,tnelhavet eburdenvfproviseomwitdidnot:year 304 ROUGH ELECTRICAL :.---
completion, . .. .
completion,IM1rp.n, -builds will have the burden of proving that he did not build or 505 - FINAL ELECTRICAL
improve for puryose o(sule.),
.. ...-.__ . ____. .___._._ e...._ .._ ,
°Lnct ther,up propcny am Business and
n,Cade:)
Cmu tors to " FINAL- PUBLIC" ' ""WORKS "_; „- -
- -_ coeswd the project(Sec.]04a,Business and Professions ilds., The s.dharo o. _
r License law does not apply to an owner of properly who builds or improves thto due r"
' .undwhocontractsLicens forsuch.pmjecrs with a.comracmr(s)li<ensed pursuant,mocha ....... _ _... _._. .. . ._. ..... t ,
C nwmors License Law.
r ❑I am exempt antler Sec. ' ,B&P C for this reason 1, ,
Oviner. Data ' " -
"' WORKER'S COMPENSATION DECLARATION
` .t I hrchy affrtm under,pcnahy of perjury one of the following declarations:
.� ^p ❑ 1 have and will'mainmin a CcniBcme of Conscm m self-insure for Wmkcr's
L,y Compensation, as provided for by Section 37M of Ne Labor Code,for the
_ performance III he walk for which this permit is issued.
°1 have and will mninmin Workers Compensation Insurance,ai required by Section
37M1 of the Labor Code.for the performance of the work'for which this pentyl is
issued. My Workers Compensation Im i rid PnI mhe a e:
Cute. 'F]POI cyN5/SqZ-�1>4(�j
OOONNN It 52 ._. _. ........
P CERTIF 1 NOFFXEMPTI FROM WO KE S
COMPENSATION INSURANCE ` )
.,
fThsscctlon need not bc<.mpltved if the permit is for one hundred dollars y ` 't'•a - 11 , v i5;1.
(8100)or]e%ls.) r ,
LLt .I comfy That in the performance of the o k Ter h eh th s ct to t a ass d I ''-
sit emem IO an .. .1 ,.i'. i? '
p y y person in any manner is 1.become subject to the Workers
,r
r so
Cnmpensnli.n Laws mf Califnmia.Detc' -
ApplicavL
CAN'D
.
NOTICE comesubject
APPL the
If.after Compensate this Certificate of Labor Exemption,you you
muld
st
become subject m the Workers Compensation provisions of the stator Code.you must
Q O furl Ih comply with such provisions.r this permit shall be restatedIrevoked. -
„�,.. .. ... _soot r I.EN soot... ..,
F'> ••"CONSoreisa ONLENDING AGENCY
ai > � 1 barely affirm that there is a c.nswcu.n lending agency for the perf.irnance
W a.f -of the A fM1¢h Ni.perm t ssued(Sec J09],Civ.C)
Q. ..I,knd Name _�. - _ .....
Lcd Address' ... ... .i .,�r
1 nify that l have read this application and sine dim the above infom ai.q is
kx [r bbmeol I agree i9 comply with all city and county ordinances and state laws mlating
Q:V to Wilding construction.and hereby transport representatives fthtsety to enter upon
Li: fficidi.va-memmed property far inspection pure e
y.A, (W)agree to sa ndmnfy and keep harmless the City 6fCpen .'against
VJ firbilides.pillriniards,cm.and expense[which may in mY y ccon,against said /
V.^ Ci 0,in consequence of the gmming of Nis permit.
APPLICANTUNDERSTP SANDWILCCOMPLY WITH ALL N0`:POINT"
'6 UR eR r Tlo' I Issued by: Date ko—
Sig KJ
1' p icanlrcentrect.r ." '.^ ", . " Re-roofs
- HAZARDOUS MATERIAL1 :S DISCLOSURE , '
'.; Wll the epplcent r(umrt budd'goccupant store or handle haiardous mamtlal ,.-Type of Roof-.
as defined by th C pentno Mu c I Code Chapter 9,12.and the Health d Safety
-
Code Section 25533(x)
yl 4
-All roofs shall be inspected prior to any roofing material being installed_
W Il,h, pphcant t bu Idingocc pant use equ p nl rde ices which If a roof is installed without first obtaining an ms ecnoni'I a ree'to remove
.rod halartl.ts air contaminants as defined by the Bay Area Air Quality g P g _ ..
Diane" all new materials for inspection. Applicant understands and will comply with
°Yes .. .. _
all non-point source regulations.
1 have read the hazard us materialsrequtremem,under Chapter 6.95 of the
Caltfomm Health&Safety Cade,Sections 25505,25533 and 25534.1 understand that
if the Wildin does not cuneml have.h tmnh flat it ism - - - - -- --- - -
g Y y respoca of.Cenisnify the
occupant.(the aquiremdn¢which most be inn prior m issuance.f a Cenif@me of
rz Pe y Signature of Applicant Date
G b drzp ng nt 1 mc0� All roof coverings to be Class "B" or better "
tots .,
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.t.:. -. ... . �' .. toss - - OFFICE .. _
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