05040167 CITY OF CUPEWfINO
BUILDING DIVISION PERMITaCONTRACT(IItINFORMATI01 t
BUILDING ADDRESS: PERMIT NO.
LUAN CONSTRUCTION 05040167
OWNER'S NAME: PERMIT ISSUE DATE
C:
RE), 4433 In
SANITARY IN 0 OL N0.
ARCHITECDENGINCER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
u00 LICENSED COMPACTOR'S DECLARATION Job Descri tion
I hereby affirm Ila,1 am licensed under p,nvisio-s M Chapter 9(enmmencing p
ior with SCOII.m 70M)ofDivision 3 of Ne Business nd Professions Code,and my license is
in full force and effect.
5'qi License Class Lica REVISION- -REVISE CLOSET SIZE
_ Dat° c""Ira`ror NO NEW PERMIT ISSUED/ ORIG. #04060231
ARCHITECT'S DECLARATION
I understand my plans shall he used as public records
Dyu
301- Licensed Pmfcssiomd
S OWNER-BUILDER DECLARATION
CrobaON < /
<f 1 hereby.ffi,m that I am exempt from the Cnntramnrs License Lew for he \ rT
00 fallowing eas.n.(Section]fn 1.5.Business and Professions Code:Any city or county V p
K$ which requires a permit to construct,alar,improv.,Jcmnlish.or=pair any strucwm aJC.
m-•'^ prior to its issuance.also requires the applicant for such permit to file a signed statement
That he is licensed pursuant in the provisions of the Contractor's License Law(Chapter 9 Sq.Ft.Floor Area ,! Valuation So
e�$
(commencing with Section7ME)of Division 3 of the Business and Professions Code)or ��
..
that he is exempt Nemfrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant no a civil penalty of APN Number Occupancy Type
not more than five hundred dollar.(1500).
DI,as owner of the property,or my employees with wages as their sole compensation, 369301 00
will do the work,and the snumum is not intended or offered for sale(Sec.7044,Business
and Prossions Code:The Contractor's License Law does not apply to an owner of Required Inspections
fe
property who builds or improves hereon.and who does such work himself.,through his
own employees,provided that such impfovemenu are not intended or offered for sale.If,
however,he Moiling or improvement is to within one yeas of completion,Ne ownc,-
builder will have the burden of proving has he did not build or improve for propose of
sale.).
D 1.as owner of he propcny,am exclusively contracting with licensed comranors to
constr.m the project(Sec.7044,Business and Professions Code:)The Contractors Li
cense law does not apply to an owner of propeny who builds or improves here.n,and
who contracts for such projecu with a coulmoor(s)licensed pursuant to the Contractors
License Law.
Dlam exempt onB&P C in his reason
t
Owner_ Date
_�OOMBFNSATIONDECLARATION
I hereby affirm under penalty of Perjury one of the following declarations:
I have and will maintain a Cenificen of Consent o self-insum for Workers Cumpcn.
sation,as provided for by Section 37M of the labor Code,for the performamx of the
work for which his permit is issued.
D 1 have and will maintain Worker's Compensation Insurance,as reslvied by Section
37W of he labor Code,for lie performance of the work for which this permit is issued.
My Workers Compensation Insurance carrier and Policy number art:
Canter: Policy Na:
CERTIFICATE OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
(This section need nut hecmuf lemd if the permit Is forme hundred dollars(SIM)
Others.)
1 ccnily Not in the fnnnance of he work for which this permit is issued.I shall not
employ any person i egch to become subjecuu th otkes Compensatio
Laws of California. G...J\^� ��1T�00:
Applicem /-I9 �— --
becomeETOAPotheWorer's Compensation
this CcniusOfrem thof e hotiodyoushould
becomesubject
coto he Worker's Compensation provision of he mem"hot Code,you muss
,JOforthwith comply with such provisions or his Permit shall he deemed revoked.
Z CONSTRUCTION LENDING AGENCY
{-r4. I hereby affirm that here is a construction lending agency for performance of
C> the work for which this permit is issued(See.3097,Civ.C.)
WW Q Lender's Name
.7 z Lender's Address
U O 1 ccnify that I have read This application and tam that the above information is j
ak.F corm.I agree to comply with all city and county ordinances and state laws relating 10 r/
p U building construction,and hereby authorim representatives of his tory m row.pnnthc r
above- cmses.ioned propeny for inspection purposes.
F mG (We)agate I.save,indemnify and keep humlcss Ib.City of Cupeflino again.-
SOliabilities.ju myll,cos¢anxnms which may in anyway accrue against said City
U z in const,.,- of he gra ming odcpcfthispiumul.
r. APPLICANT NDERSIfANDS AND WILL COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE RE TI NS. 6i —
2� 5 Re-roofs
Signature fA .ntre or Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant or future building arupant more or handle havardous material
as defined by the Cupeninn Municipal Code,Chapter 9.12,and the Health and Safety
Code,Section 25532(.)? �° All roofs shall be inspected prior to any roofing material being installed.
D Yes
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
mit hazardous air comaminanu as Jcfinod by the Bay Area Air Quality Management all new materials for Inspection.
District,
DYcs D(Nu
1 have read the hazardous materials requiemtnts under Chapwr695 of the Califon
ria in&Safmy C.M,Sccdmss 25Y)5,25533.d25534.1 understood that if the W,Idi.,
does not cure have a anent.hal it is my espunsihility to notify the necupant of the
requirements is in me rimmissuenccnfe c of�ogt/q.pamty. SignatureofApplicant Date
'
2z 449 All roof coverings to be Class "B"or better
O W"Ct ll! 0 1 ale