02040116 Cl BUILDING DPERTONNO PERMIT CONTRACTOR INFORMATION:
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S:, PALMA LA R & Z DEVELOPMENT COMP "Rt 02040116
OrER&N21E,:DEVELOPMENT CO. 1601 S DE ANZA BLV Alolf)TT�Sft` Ti52
S•.HONE: (408) 252-1101 SANITARY NO. CONTROL NO.
n ei O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
e.- BLUE ELECT PLUMB MGCH
to
5HDescription
= LICENSED CONTRACTOR'S DECLARATION Job Di tion
z_e 1 hereby affirm that I am licensed under p f Ctapmr 9leommencing DEMO p
wF with Senior 7000 Dirision3ofthe Basin eS,c�n ���nnnaC e.andm license
is in full fn c 7 '/ /� 'r
z a License Clas Li t'. / o•L-I
O n O Da Comtncmf
i LL 0 C EC'1"5 DE pATION
Y 4 ,^ .rst^»e t ria beyscd c mcot�
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OWNER-BUILDER DECLARATION
uai='a 1 hereby affirm that 1 our exempt from the Contractor's License Law for the
t?a following reason.fsaedon 7031.5.Business and Pmrea,ion.Code:Any city or county $10000
E-o which requires a permit to construct,cher,improve,demolish,or repair any structure
`3 m pri......
Iso e9 N PPlicam for such pemuu fl 'g W m¢mem -
hot he,:1ctruWparamour_ t Ne provisions of the Conuacio' L' La (Chapter :is h C• ask y p [[ Valnat100
(, g thS ci 7000) f Division 3 of the eu3 s; JI f.:o sCace) h 1•. tlx.:'N„ tilt''. i.';t °.Y101P Il( "V N':
that he is eaimpt tha.b.m and the basis for the alleged exemption.Any violation l
of Section 7831.5 by any applicant for a permit subjects the applicant to a civil penalty-
-of not mmre than five hundred duoora Is5orl :; i. Occupancy Type
❑1,as owner of the property,or my employees with wages as their sole compensation,
.will do the work:and the'swcture'is nor intended or offered for sole'(Sec:7014, - -
'Business-and Preassinns Code:The Contme ors License Law docs not apply m an Required Inspections'^ ' '
owner of property Who builds or improves thereon,and who does such work himself
offor iV ggh F F.w Yees Provided Nat such mpro t Is sol arc not mended or
dti he woe thebuilding or improvement n sold within one y of .. _._..... .._......... .. .. . .... ..... .. __....... _... _ ..__...._
:
completion.ii n p ncr b IJ 'II M1ave the burden of proving that he did not build or ,r
improve e fo r rpo. or. I )
❑1 - th n tract iNl sedc t mrsm
onswci t p o/ t(SDP Y X.B Y s Code)Th C t nor s
P a Y w
eP f i
Lice fives nota I to a f rort ho bu M p es thereon. 3 t -
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and motors fo wn
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N EC RA O
£ hfab afrmaal perjury one fthetallow gdeclarnions:
❑ I haven 'will maimuin riificac of Consent to self-insure for Worker's
ComDensatio - as provided by Section 37130 of the Labor Code, for the
performance fthe work for which this Permit is issued.
❑1 naves will maintain Workers Compensation Insurance,as required by.Section
- _ 3700 of the Labor Code;foi the performance of the work for which this,pennii is
issued.My Worker's Compensation Insomncc canier;and Policy number arc
Cem t a o t .S A EPoI y Nu. p.Ly a s _; i 'r a' '
ii:f CERTIFICATION OF EXEMPTION PROM H ORKERS r'- ti ,v .t ). b![is
(Hat ua o '<ed not be oo 70Ni1NSURANC1.E
COMPEN
SAl
IS I08) less.) mpleled dthepermns for ehundred Ilms '( f .f _ __- t --__----
pp r.. ..._ _...-.
iiA,not cmpYY' i he p any tau<�s cu2'- this t ksukcrsl
Compo 'a la ie Dq '
Applan
NOTICE
becomeoonp o mrus. p iron y, Code umust
Zs
zforth ih mih. 1 p naso ill p ish�ll J e-1ey ;ed.
{„•-� 3 ` 1 -''C NSTRUCTION LEND GAGGNCY ' - - 1 _ .-, " '- ""' ""
�_� Ilrebyaffemt anh nswa' lending age cy for the performance
r o/Newark for which pc 'i' mszuW(Sa 3097 Civ.C) '"'
LD Zlr
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U-� 1 en fy4h tIM1 Jth' DPI' t d t t Nuh aw formihimt is
(L [.. Rorie t 1 e6 to p1Y th II ty' c b' a es ane t t laws rel t
(',) tab Id ng co t i by t Jize p tolivea mf Msc'tymenterupon
�r k7 th emRen<d Pr c y nspc tion pure tts.
rF-i zA abl e)ag to a dem ify Jke ph fathcCty ofC ri noegainn �—'
U ZPgtm� STAi n g 'I �h C h YYin Na'nY N n(strfsaid Issued by:
r Date /
0 2—
o t e m ADDrcan con toate
_ Re-roofs
RI �.
' H AI S MATEA DISCLOSU6. .
. ii Neapor m w
ph. ilding compam Hari nr handle in rdobs material. Type.of.ROof _. ...
as defined yth C pen Mu IF N Chapter 912 a dth H IN Safety
cW oto: z553115 f N t I•,: i ..r "• :.t.. Y.f ';t.-..• . + ..,- -,�-
' ' ') r _All roofs shall be inspected prior to any roofing material being installed.
wu m ppl' t f bo Ism g p t s equipme t a 'e wn h If a roof Is installed without first obtaining an inspection,'I agree to remove
imthrad nt nu is off ad bah B yAm.A Q Ii,M ,amain
. `stnaov �❑ry - _ all new materials for inspection Applicant understands and will comply with _
all`non poinCsoi lice tegulahons
I ha e d s mq 6.1s 'i rcmeas uncle Cb pt 6 95 of the
-
C' iomiaHeahM1& of yC ase ons 3555.25533 and 255341 dernvnd that
I t din does rot ren y ha a¢nam that it is my m Z,c Csibi to try
"' - - - - - ------ - _ - - ---
O` e Maui is fiic ui b< n It to iIs. of
c u en e.m - -
r
Y f �i Signature of Applicant Date
. _
n to.nmeiaed int: All roof coverings to be Class "B"or better
OFFICE