01010001OFFICE
` nuIDIDIVISION"PERMIT
CONTRACTOR INFORMATION:
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BuiLlu4dla"s:FAR60 DRIVE
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$1mIIZ0,
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SANITARY NO. CONTROL NO.
CHITECT/ENGINEER:
BUILDING PERMIT INFO '
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BLDG ELECT PLUMB MECO
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LICENSED CONTRACTOR'S DECLARA CION -
Job Description
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I hereby affnn Inns into licmmd pnd Prof orchnpter 9 (coma enense
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wimsernnennonarumiLl"n3anhenateln"a,nndPn,resensend license
CHIMNEY REPAIRsn
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Date Q,(- 4_(— Crup
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ARCI' SDECLARATION
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my plans shall usedas Tonna records
Licensed [',at ..ideal
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OWNER -BUILDER DECLARATION
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1 M1eieny affirm that 1 am exempt from the Contractor's License Law for the
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following reason. (Section 9031.5. Business and Pofewbne Cade. Any cily or unmy
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which requites a pi,ant to construct, nher, improve, demmll.h, or repair any saucturc
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prier to t'. L rectum, ihpiliconet sherp It file a signed'I emera
S([.F't. Floor Area
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V3166
mallre i, licensed carsoundatl the precision, of tire Ciamicone, t La (Chapter9
(aa g with Section A)IB f 91Dickion 3 t f the It missend P .fi sista s Code)
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$ 1 3166ton
or that her escort thomfema, and the basis far the rlleged m
excntptn. Any vieladon
of Section 9031.5 by any applicant for u permit subject,, the nppl'mam to a civil penalty
« hot mone than five mnmrmdanam(&soo).
�p giber
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- Occupancy Type
3tib.301c�. tZlfLl
El 1. atlon.
owe i ofvour ncpopery, "nlure dee
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d is at into
will do the work, mW the siruauo is not intended or altered for sale (Sea 9014,
I),vsfsedla"1e a (S,d,
Businessand Professions Chile: The Contractor's Etudes,, Law does not apply to an
red 'Inspections -
101
owner of property Who builds or improves thereon, and who does such work himnclf
a — FOUNDAI-�LiiVg
or though his own employees. provided that ouch improvements are not mended or
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ant a f 1 If. n Inbuilding pine t :: 11 Id year or
of
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312 — CHIMNEY RERAR R'' STRAP'S
ce mpl I the h ll 1 Ih burden f noting I did t build or
rap f pm 1 l.)
51.4 - FINAL PUBLIC WORKS
rane
E3 1, a f he p ty :. ly I l 1ed 11 dcontractors
construct II project (Se 9,
lk m d profession s C ic ) " Contractor
L d I TuI property h bu 11 p t
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an
.Ind h contracts ( such p 3 r. unit acontractors) I pursuant t tire
Contractor Lecom 1,
❑ 1 nm octopi order Sec. , B & P C or this reason
Owner Date
WORKER'S COMPENSATION DF,CLARA3'ION
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I hereby I f iho under Torah, of perjury an .1 live following declurtion.:
❑ 1 hove and will maintain a Cetina:ne of Consent m self-inmtrc for Worker's
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Compensation, as provided for by Section 391111 or the Labor Code, for the
rhareance of it,, work for which this permit Is issued.
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I have and will cani union Worker's Compensation Insurance, as regnimd by Section
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OR of the Lunor Coda for the ped"orniance of the wok for which this permit is
door. My Worker'. Compensmion Insurance carrier and Policy number are:
No
GvrieeSTa�t Fr�11
FIcy
C: IPICAC NONE. F,MPTI INSURANCE WURKF.RS'
COMPENSATION INSURANCE
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('Phis section mewl not be completed If Inc permit is for end hundred dolours
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'BI W)nr les.)
I certify that in the performance of the work for which this permit Is i.caned. I
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Fhall T y r t n^.� . ti ?t In w 1Aor,G),,,,toy
cY_r o hO
L ANT II k t Crlf 'I IE PI y .heal)
ct, theW A Couipen man provismas hills, LahmCcahc you oust
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[nthw'Ih cr mply wvh meh pnrvianns � rah n Ter i I nhall bt Jcemed rmnked.
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CONSTRUCTION LENDING AGENCY '
1 hereby %Bich that there Is n constructione.lending agency for the performance
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of Ire work for which this permit is issue) (See. 3099, Civ. C.)
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Lender'sNamc
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bender's AJAresa
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Icertify that l have readthis application and state that therbova information 1.
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camel. I agree to comply with all city and cnmdy ordinances and state laws relating
la building construction, and hereby authorize mpreaenntives (if this city to enter upon
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the %hove-ntemianed property for inspection pumoncx
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(We) agree to save, indemnify and keep hamdess the City of Cupnaino against
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liabilities• judgmmnts• cods and circuses which may in any way acme stains, cool
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City in consqucuec of lad pruning of this permil
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A ANTUNDEil TAN AND WILL COMPLY WITH ALL NON -POINT
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Issued by: Dale
S, t GRF ULAIII )NS.
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—usink
Sitnmu nfAPTlic.ntlCanlractor. !— War
Re -roofs
HAZARDOUS MA'r' "ALS DISCLOSURE
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ill the m,plicam or fin e, building ocsupum sols m leandle auditions mawdid
Type Of hoof -
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us defined by the Cupdrllno Munlelpal Cade, Chaam 9.12, and the Hadth and Safety
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Code. Section 25532(%)'/
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All roofs shall be inspected prior to any roofing material being installed. -
Wietheappna%n,to future naiwingoreu,sual soa,.ipmenlordemeeswhima
If a roof is installed without first obtaining an inspection, I agree to remove
emit hazardous an comaminants m defined by the Bay Area Au chunky Managmneat
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all new materials for inspection. Applicant understands and will comply with
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all non -point source regulations.
I have rend the harmdous materials rcyuiremcnt,, under Chapter, 6,95 .1 the
Ilm nie Health A, Safety Code, Sections 25505, 25533 and 25535. 1 understand that
the building does not ciamenly have a mount, that it ie niy neTe admilim a, ramify the
- am of she rey "mmmts which ams, be mel Trier to issuance ofd Ccnincute of
Gest a ey.
Signature of Applicant Date '
own t name, ed .gen, r�li� - - Data
All roof coverings to be Class `B" or better
OFFICE