04070116 CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT 'CONTBA-TORANFORMATION ;q.
BUILDING ADDRESS: PERMIT NO.
04070116
R12 FLARGO DR OWNER'S NAME: PERMIT LSSUE DATfi
'2 a
E: SANITARY OL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
LOo LICENSED CONTRACTOR'S DECLARATION
=�u 1 thereby affirm that I am licensed under pmvisions of Chapter 9(commencing Job Description
with Sud ] )of Di ilio Sof the Business and Pro(cssiom Code.end mylicense is
� „ Nfuuroreeaaerra JN J/ 322 ADD 277 SQ. FT. (DINING RM/ENTRY)
Jaa�? License Lic.N
w Do Q 7IL�Comnecmr pCONTRACTOR: WEST COAST DEVELOPMENT
Z AR HInl(C S D ON
I undcmond my plans shall W used.pts seem l
J,U
;oH Licensed Professional
3 - OWNER-BUILDER DECLARATION
1 hereby million Not 1 am exempt from the Contractor's License Law for the
00 following....(Section 7031.5.Business and Proficom.Code:Any city ar county
K m which requires a pcmtil to construct,alter,improve,demolish or repair any structure
poor to its issuance,also requires the applicant for such permit in rile a signed statement
�s< Nat he is licensed p..art to to pmvisiamoflhc Crmrecmr's TJccnu law(Chaprer9 Sq.Ft. Floor Area ValUa24OFtQoo
as (commc.cing with Seetion]000)of Division]of the Businessand Professions Cooke)m, y�b�
Nat he is eumpi IMmfrom and dre bazis for the alleged exemption.Any violation of
Section 7031.5 by any applkadh for a permit subjects the applicant o a civil penally of APN Number - Occupancy Type
not mom Nan five hundred dollars($5001.
❑T,uowneroftheproperty,mi. employees withwageu Noirsole compensation,
32630120 . 00 "
will do de work end Ne 'Corsa tri not i Liven ora w do(.,,Me(Sec.7014. weer v
and Professions Code:ITe wsthemon, ndwho Law Docs not apply lf an owner of Required Inspections
Own etty who builds oded thawch iodpho mad who doessuchwork h 1 offered
for ugha de his
ownevct,m building
Natsuchimpm old within one
arof rl cm,Rema for Owner-
buildc' .Nebuildingorden of pmcnlissoldwithinone ild or completion,Nc owe of
bueacr will nave Ne burden of proving that he aid not Wild or improve for purpose of
sale.).
❑h as owner of the property,am exclusively contracting with licensed contractors to r!
construct the pmjca(Sec.703.,Business and professions Cade:)The Convection's Li- Y
cense Law dors not apply to an owner of pmpcny who Wilds or improves Ncreon,and /
who contracts for such projects with a convaaor(s)licenmd pursuant m de Contractor' -
License Law. / C
❑Tan,,memtunde,Sm .Bk PCforiniareamn
Owner Date /
WORKERS COMPENSATION DECLARATION
II' )I hemby affirm under Penalty of perjury one of the following declamations:
\- daw and will maintain a Cerafiam of Consent m self-insure for Worker's Compcn- \ .
sign,as provided far by Section 3]00 of the later,Code,for the Performa..of the
work for which this Permit is issued.
I haat and will maintain Worker's Comp mxruion Insursoce,ss myuimd by Section '
3900 of the Labor Code.for the performance of the work for which this PCmtit is issued.
My Worker's Compensation Insurance
carrier and Policy nummber. r✓/�� O
CamP�✓��U�.� Policy Nebo//6�E'Js1A
✓`
URFICA OF EXEMPTIONF WORKERS
COMPENSATION INSURANCE
(This union need om W campleed if The permil is formic hundred dollars(SIM)
mar Ica)
1 cerdly that in Ne performance of me work for which Nis permit is issued,I shall not
employ any person in any manrcr sn az lee Wcomc subject m tW Workcrs'Crmpensaurn
Laws o(Califomia.Date
Applicant
NOTICE TO APPLICANT:If,after making this CCNBeale of Exemption,you should
become subject m the Worker's Compewlion provisions of the Labra Coat.you must
.JO forthwith comply with such provisions or Nis permit shall W deemed revoked.
Z"" CONSTRUCTION LENDING AGENCY
P'4 Ibcmby affirm Nm there iso emairmfinn Indio,agemy for the pefurmanec of
im the work for whim mit this peris issued(Sec.709"!,Civ.C.)
W
Q LanceAddr's
Name
a. Le
G nders AOarcss
U O 1 ecrdify Nat 1 have read this application and sum that Ne above information is
LL F correct I agree to comply with all city and county ordinances and seem laws relating to
�O building construction,and hereby authama representatives of Nis city to enter upon the
r H.1 alwve-mentioned property for inspection purposes.
(We)agree to save,indemnify and keep harmless the City of CuNninr against
F'y liabilities.judgments,costs and expenses which may in any way accrue against Mid City
V z
'a PL
uncUNthe gra NDSIAND WILL COMPLY WITH ALL NON POINT Issued by: Date
SOURCE REGU NS. _
Re-roofs
igo. plicanV r Date
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will de applicant tar future building mcupam Store or handlehaous material
defined by the Cupenina Monte' al Code,Chapter 9.12.and de Health and S6,,y
crde,S.tio.255J2h)' All roofs shall be inspected prior to any roofing material being installed.
El 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
hazardous air conmoo tar y acancd by the Bay Area Air Quality Management - all new materials for inspection.
❑res
I have mad Ne hvaNnuxmamoals rcyuircmenu under Chapter d.9Saf de Glifor-
niaHwlN&Safety Code,Secdalu 25505,25577 and2S53d.1 understand Nazifdc Wilding
docs not currently hart a moan Nat it is my msponol ility m nomy Nc vcupam of the
reyuimmenvw ' stbe I 'ssuan.ofaCcndfinmof upancy Signature of Applicant Date
norm aumroved agent bDo. All roof coverings to be Class "B"or better