01120008 CITY
BUILDI c DII ISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
1491 DE ANZA BLVDyy 01120008
GYM"MRIA APPLICATION SYR
noPHONE: SANITARY N0. CONTROL NO.
. ARCHITEC(ENGINEER: BUILDING PERMIT INFO
w O BLDG ELECT PLUMB MECH
a i
LICENSED CONTRACTOR'S DECLARATION
D S y I hereby z1Hrm that I am licucsed under provisions of Chapter 9(commencing Job Description
ms«tmn1000)arD ' n3anheBr,mes,anaPwfeaammCod m e 1 MONUMENT SIGN, 1 SET NON—ILLUM LTRS
yyg,,j is in full frame de 1 .�
m a Liana Clare t r 2 Lic.p
I 3 Date aa— Comrwm
LL O G RCC}tttfRrEEC1"5 an OF
g I understand my plan,shall b med as pu he records
E5�
1 a.p p Licensed Profc,>ionul
d OWNER-BUILDER DECLARATION
i Z"-' I hereby.(firm Ihm 1 1. exempt from 0<Cession, o License Ww for the
z< following re n.(Section xuls,arafne,.am rrvre..ann.coda Any<hy rr<oantr $3000
w
ne on Fa which requires a permit ac uiresrve,palm�plic improve,demolish,or repair any structure
a. donne slicensed also requires shcvisions o for Contrauch rminoamile a,Law(ned cmement. ......_
nomeish«nsmhSeelitwmeptansii,i.n3 CcBusinnLindPaLaw(CwCmr9 ._ 36,®,1�,1t)3i,®teag•. Valuation
(commencing wird Section 1000)of Division 3 of the Business and i.h.An vi Code) `!"+i!. {,,• ai'
or Sect he is 31.5 b therefrom and the burs for the subjects
he PPILc t In Any violation
of not.1th n v any upplicontfor a permiwubjmsthe applicantmacivil penalty
nmol mom twit nue nmwtea emlar.(sspo). 10 lApN ll!'�ATI ON Occupancy Type
ID 1.as owner rime properly ar...y employees with wages as that,sole cramvamari.n.. 103 - UFER
-wppdo he wrrkraad the'.ommm ,a.,inmaded it offered'for.1c(Sea Tfkm,' 104 - REBAR Required Inspections
Business and Professions Cod,The Contractor's License Law does not apply w an
man
m of propmy WM,builds or improve.thereon,and who d«s such wort himself 105 — ANCHOR BOLTS
or through sal own employehowever.t provided mat such improvementsis sola i not me-,std or
'pBveG far rob.u.hrwevec theWildingti.wld within not r - - - -304 "= -ROUGH ELECTRICAL;. -- --- '-' -
g or impwvemcn year a
amprove(nrm<ownerfsale.',will have the burden of proving mat he did not build or 505 — FINAL ELECTRICAL
improve paryrsco
qL oftheedsivdycontracting with l rinsmcontractors. o 514' — FINAL- 'PUBLIC WORKS
constract the major (Sec.10F1 Business and Profess ons Core')The Contractors
License Law does not apply to an owner of property who buildi or build. improves thereon,
1. and who contracts for such projects.with a contmetoos)licensed pursuant to me.. _-
- -
Contractor License Law. .._ ... 1� ._.
❑1 ser exempt under Sec. - B&P C far his
- Owver Date /
. WORKER'S COMPENSATION pedur on DECLARATION
I hereby affirm under penalty of perjury one rfin<following declinations:
❑ 1 have and will maintain a Certificate of Conant to self-insum for Worker's
Compensation, as provided for by Section 37M of the Labor Code, for the
performance of the work for which this permit is issued.
❑1 hine ad will maintain Worker's Compensation Insurance,as requited by Section
3T. of the I�bor Code.far the pearfortwnce of me work fa winch this permit is
_ isuad.My W inpensation Insurance canter d Polic umber :
,
Policy No.: n' are �..
f :"i CERTIFICATION OFEXEMPTION INSURANCE WORKERS.)', t1-•` �.:•°. -1k
- COMPENSATION INSURANCE
(Ths secnon need not ba comple d if the permit is for one hundred dollars t' +
($100)or lass.)
I anpl mat in me n in
a n me work for whim this pcmdt is lured.l t ),'C
shallCom not employ any pawn in any manner w as m become
subject to the Workers - '
Compensation Laws of California.Date
AMficaunt
NOTICE TO APPLICANT War:isIf.aftCompensation
this Certificate f lh Exemption, y nM1ould
arm, i.
zZ become subject coey the W'orker's Coionsor his permit'hall the Labor Cala you must
C forthwith comply with such provisions or this permit shall be deemed tanked.
CONSLENDING AGENCY •..
6a I M1 by Irmin thantheem.,.cons t t lending ag ncy for the pcdortnantd I ,
rf me rood Tor which mtv pmou rs issred(Sec 3091.civ:C.)
Lencer's Name.. :. . :........ . . ... ...
V6Lentla's Aadres.' _
0 .,.1 anify mat I nave read this application ana xtme met thaabove information is .
'coned.I agree to comply with all city and county ordinances and sure laws slating
U to Wildiagconswaion,and herebYaumonve representatives'ofmis city treater upon
W the above-mentioned property for inspectionpun o"
.Fi 6 (We)egreem save,-indemnify and keep harmless the City of Cupanino against
Vi
liabilities,judgments,costs and expenses ti h may in any way accom against said
C.7-Z City in-consequence of the mmhtg m pertri t. "
APPI]CANT UNUERs D LCOMPLY WITH ALL NON+POINi -
sou�I f? In.AT Issued by: Date
s rappl n a<m LS Date Re-roofs ? O f
HA DOUS MATERIADISCLOSURE
Will the appl c t w(urate W ldi g occupoa store or handl hazardous mstenel
as .Type Of.ROOF
defined ned by the en Cupno Municipal Code Chapter 9.17 and the Health and Safety ty �. - -- - ...... - '- -
Code s l on 25532(a) T l - -, ,. ._...
All roofs shall be inspected prior to any roofing.matenal being installed
t W ll me,ppc_ t r t Wilding ge occupant uaeq p sou res Winn If a roof is installed Without first obtainin an ins ection,.I agree to remove
cm t heard rata is as defined ing by the Bay Area i Q al ty Management g P g
Di t t all new materials for inspection.-Applicant understands and will comply with
oY oNr all non-point source regulations.,t .
have coed due'h;iIdous materials mquismern'under Chapsr iiM of me -
Califowi s H.Ilh&Safety Code,Sections 25505.25533 and 25534:1 understand that
ii,n Wilding docs not comically have a lenam.that it is my responsibility m mufythc - '--' - - - -
occupant f ma requi ¢vb< t met prior to issuance of a Cenificam of
a �� Signature of Applicant Date
w�rr=am�reayeg�t i - Date All roof coverings to be Class"B" or better
- -OFFICE -- .