00120154CITY OF CUPER'1'INO
CONTRACTOR INFORMATION:
BUILDING DIVISION PERMIT
BUILDING ADORESS10121 FOOTHILL BLVD
G
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PERMIT NO 001220154
'OWNER'S NAME:
APPLICATION SUB DATE
ATLANTIC RICHFIELD COM
ANY.
12/28/22000
ONE:
SANITARY NO. CONTROL NO.
ARCI111 ECT/IiNGINFER:
BUILDING PERMIT INTO
R EL PLUMB ME H ,
L
LICENSED CONI'RACIORS IIECLARNTION
Job Description
p
I hereby nnirm that I :Ion licensedunderprnvnl� rchYqter 9 (rmnon
neneing
with Section 70fNBof Division 3 of the l.% 4 �P I i ypde. nnJ my lkcrose
I.m fall ferre nd•f
:reense Class 4;.7 I.ie.M_n 10Ll 90 9
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TENANT IMPROVEMENT/ HANDICAP RAMP/
Dnte Cantraetm n,pp� �i-fC
-� 3 7RG111'I'I:GT'SDl:`: TIDf(�r1� -rY-a
,1 �1
�LWa' IhtiC,
I undertmnd my plans shall fe used as public reconiv
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Licensed Fri onhl
OWNER -BUILDER DECLARATION
,
1 hcrehy nfli nt that I aro exempt fiont the Conouvnr's License Law for the
following ree,nn. (Scallnn 7131 5, Business and Professions Gale: Any city or county
which requires a permit to construct, alter, nopmve, demolish, or repair any swemm
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prior in its issuance• also re9uim.s the applicant for such Krmitto file a signed statement
Sq. Ft. Floor Area -
Valuation
that he is licensed pursuant o the provisions of the Gmoacmrs License law tChapter 9
(commencing with Section 7004) of Division 3 of the Busi nccv and Pronasions Code)
or Ib:n he ix raempt therefruon mu1'the bnviv da the alleged .cntpdou. Any vlismion
of Section 7031.1 by any applicant or a permit subjects the applicant to a civil penalty
of nor more man five hundred dogan(55(10).
APN Number
�CCnpaDCy Type
01. as owner of the pmpc ty nr my employees won wages as their sole compensation.
will do he wore. and he etniumrc is not ialead,sl or otfervitior pec (Sic. 7Md,
Business and Profession, Gxlc: lire Cmm,a,ba'. Licetnc law dn
oes not ply to un
Required Ins ection5..
ownerof property Who holds or improves and who encs such wore himself
of thugM1 mhis wn employees. provided matat such such impmvenente ore not intended or
named for sale. IL building or improve n mW within one year of
banner
completion. the awneohuilder will beast 0c huNen of proving that he did no, build or
ownerpow
Inrpntvc for pnrstec of
01 ofthe property. si ly ciarmasti., with bramod cordradour,ul
consumer p sect (Scc. B 1d Professions Cone:) The Contractor's
License La not apply in r of poy who funds orimproves thereon
,
Cuulio'couirectslor suchI l t anti tat ts) licensedP ttmthe
Co t Ii an. Lose
O -
❑ 1 am exempt under Sec. , B k P C for this reason
Own Data
WORKER'S COMPENSATION DECLARATION
I hereby affirm under permlty of perjury one of the following declarations:
,
1 have and will numadom a Cenificate of consent m sclGimurc for Worker's
unipensatiun, as pnn'ided fill by Section 3700 of the Laher Cale, fur the
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performmrceofine work fnrwhich this permit is Issued.
Vand will maintain Worker's Compensation Inmmove. as reyuimd by Section
GI of the Labor Code, for the fm his is
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perfomtance of the work which permit
i ... edM W.lo,6 Coomm
Insurance artier and Policy number arc:
pper,mon
Cnn'rcrLh�OIC,-ASI ItOrN A)AE
_oO
unif (IIn EXEA1-oli�lON��FROM
COMPENSATION INSURANCE
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mssection need not be completed if the permit is for one hundred dollars
(810x1 or leas.)
I cenify Ihat in he peof in ole of the work for which this permit is issued, l
shall not employ any Perron in any mo me, so as or become ..bidet ,o the Workers'
Compensation laws of Calimmon. Dam
Apdrenm
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NOI ICE TO APPLICANT. If, It,, nuking this Cenificate of Exemption, you should
become Indo Lm he Workers Compensation pmvisiensnf he lsbnr Code,you muse
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forthwith romply with such pmvidom or this Komi, shall be deemed rtvokML
CONSI'RUC`fION LRNDINGAGLNCY
I hereby oflirm ohm there. is , cunmractinn lending a my for the penbnnance
of the work for which this paean is issued (See 1097. Civ. C.)
Lender's Name
Lenders Address
s ,
1 cenify that I have rend this application and ,are In;,, he ahnve in Runtmion is
' o
Mall1t. I agree to eonmly ,In all city and county oNinrnces and nate laws relating
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to building comnricum , and hereby moorim representatives of this city at enter upon
the above-meminned pmpcny far inspection pursue,
(We) agree m save, indemnify and keep hnrmless the City of Canadian ,din ,
liabilities, judSmmuts, costs and expenses which may in any way recite against said
Cu, In consuyuenee of the gmming of this permit.
APPLInNT UNDIUsTAN SAN) WILL COMPLY W,m ALL NON -POINT
SOU/'�J1RkCy�11 0 - / •�
Issued by: Date
_�
- C-_-4�nntr r
Re -roofs
Siyn:W+•r,lAppRennUcnmr i
HAZARD US MATERIALS DISCLOSURF.
Win the applicant or far.. doldmg rxxvsmt more or ami hamNom mmeri:d
Type of Roof
as defined by the Capitoline, Municipal Cone. Chapter 9.12, and the Health and Safety
Cala Sxtion 25532m)? �/�
°Ye, IX
All roofs shall be inspected prior to any roofing material being installed.
wincen,li,un farumholding orenpant a,, cya',enantrdevicoswhish
If a roof is installed without first obtaining an inspection, I agree to remove
color hmmdnus air calm trent v as defined by the Ray Area Air Quality Alanagcancin
ni'melII
all new materials for inspection. Applicant understands and will comply with
Yes
all non -point source regulations.
I have read the humntuos mnmrinly reyuimmon.. under Chapter orfs of the
,
California Health & Safety Code, Sections 25585.25533 and 25534. 1 undemmmd bar
if the building dues nor Moremly have r mnhln, that it is my rc,prand bly In nrnify the
occupant of he rcyuimor I eh'ch must le met poor to issuance old Certificate of
Or'
i 23,
-Signature of Applicant Date
01=516wrmnr amganzed ,gent Date
All roof coverings to be Class nB" or better
OFFICE