01050189 CITY OF CUPEWrINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDINGADDRESS. PERMIT NO.
10270 S FOOTHILL BLVD 01050189 ,
OWNER'S NAME: APPLICATION SUB DATE.
RBLE—NEMVnPM1iiN 05/29/2001
HONE: SANITARY NO, CONTROL NO.
O O ARCHITECT/ENGINEBR: BUILDING PERMIT INFO
�it p BLDG ELECT PLUMB MGCH
i) Z LICF.NSHF CONTRACTOR'S DECLARNOON lob Description
O Z I h,o by afar that I um Ilfen,ed under ,proel.imu of Chaple,1)rmmmencing
P'3C will]Section 70XXYtfDivisin 13 of Ill,Bmqui,and Professions Codaand Illy license
m s m fon rnree dna effect. ELEC.. PRNEL' UPGRfiDE.
c ca 6 Lmvm,c Class Lic,a
e' a 1- Dale Commit
3 u vFi ARCHI"I'ECr'S DECLARATION
`—`to 5 I carer land my plan,,shat W reed a,public aaom.
0 C
0 Licensed Plait
c 6 OWNGILRUmp,pr m ise RATION
�t+� 1 reason .(Sa aha I an,exempt promise Cession, a License Law for the -
'Z< following mason.(Section Aorrou Business ami improve.
profession,demolish,or.Any city s manly
{F❑ which m)uisu n permit re eons the alter,improve,h Permor Impair any amount
ty3m thin he isl'cense pursuant
requires the rokines(ifant rnr sucbpennitmionn signed statement
Chapter9
tbatneistemadpunnionimapfDirvin.::r me cmmm�nes L,,it11 Law(Chapter ode) S Ft. Floor Area Valuation
or hit a is cwhh Saainn](II and the basis o loca Rosiness epon Air, i coda) q'
or met he Is anemp(any ap oi and one War Tar ma cussed pplica con.Any viomaon f600
of a.,man)3n sanymareonlrsaperm>rnimn me aprheantmgsia�penally
or not room man rve nrndma nonan(ssW). APN Number Occupancy Type
k' ❑Las owner f Inc property,or my employees with wages as their sole compensation, _3572.7,05p- Aria
will do the work,and the,aructure is not intender)or offered for sale(Sec.]BW, -
Beanes and Promssmn,Code:The Coolmmnrs Lioness,Law disc,not apply Io me Required Inspections
owner litmopeny Who hulliR lir inTook.tImmon,and who does each work himself
or through his own employees.provided that such improvements am not intended or 304 —_ROUGH ELECTRICFiL
offered for.sale.If,however,the building or improvement is sold within one year of
completion,the owner-Wilder will have the burden of proving that he did not Wild or 501 — FINRL ELEC RICRL ENERGY
prove far purpose or mle.).
`I 505- FINRL:ELrdftRiCnL"
ql nhc p p.Ir sus Ir t 1 t' g m 1 I 1 1 m '
.a mI n1 tam(S 7044n ' l Pial .. Cader'llm c noutaI does not apply t r fp pent' n builds p thereon.
h contracts for suell pit with u contractors) hcen,ei r this m(bc ' �
Contractors Liana law. /
Did.exemptM1gpder Sc q ,B&I'C for this rtamn
Owner f" �.Dale(/•J•a t_d � O/
ORKP.It'S COMPENSACIDN DECLARATION
A I hemby off under penally of perjury ane of the following declara(inns:
A 1 have and will mainmia o Certificate of Comm m alf-insure far Worker's
Compensation, as Provided for by Section 370h of the Labor Cale, for the
performance of the wvrk for which this permit is issued.
❑1 have and will maintain Worker's Contpensminn Insurance,;w nalun ed by Section
3700 of the Labor Code,for the Performance of the work for which this permit Is
i..med.My Wo,ors Cmnpmemlion Ironswc carrier and Policy rummer am: _
carrier. Policy No.: -
CF.RTFICAI'ION OF EXEMPTION FROM WORKERS' '
COMPENSATION INSURANCE
f1'1his section need not to sontpleted it the permit is for one hundred dollars -
($I00)or less.)
1 certify that in the performance of the work for which this peril is issued.P
shall not employ any penon in any manner ,,as or became object to the Workers'
Compmv:niin Law,of Culifernia.Dae
Applicant
NOTICE 10 APPLICAN'1':It,utter making this Cenitcale of Exeraplion,you Ronald '
txcomu
esubjecn the Worker',Compert ipnrvinions of the IaMm Crile,ymu mus(
C Q fnnhwi(h comply with such provisions or this pencil shall W deemed revoked. -
F gi� CONSTRUCT[ON LENDING AGENCY
a > P hereby affirm that them is a construction lending agency far the performance
of the work tis which this peri(Is issued(Sec 3097,Cre.C)
Lender's Name
z Lender:,Addle,,
U O 1 certify(hal P have read this application and state that Ne above information is
Ls. [.. correct.I agree m comply with all city and county nNirmnce.and ,am Paws minting
to building construction.and hereby authorize Teriesenmtives of this city to enter uptm
W the above-mentioned Point for inspection purposes.
6t (We)agrm to smve,rudamni fy and keep bunnies,the City of Criterion asci list
U rn belt imlgmeot,.ma.nal expanse which Duty in any way n,crne ngama(said
U City in con,c 4 ncC of)Ft:grun(Ing D this pcnttll.
API'LICAND TANDS AND WILL COMPLY WITH ALL NON-POINT
soukr GD -TONS. ' Issued by: - Date
9-0
Signaure ApplicanAr Dae Re-roofs
HAZARDOZARDO US MATERIALS DISCLOSURE
Will me arprcam m noble rill Co ocenPaht amre mntmdm mvnwmnd Safe(, Type of Roof
m ddineJ by uhc Cvpcninu Mnnialpal Calc,Chnpnr 9.12,toil @c IIcnI1M1 toil Safety
' Cody Bertin 25532(v)'! - '
0Yes )(No All roofs shall be inspected prior to any roofing material being installed.
Witt the appecaol or future Wilding oeeaparl use equipment or devices which If a.roof is installed without first obtaining an inspection, I agree to remove
real hazardous at, um
r cmmiis to defined by the Bay An.Air Quality htaiagmncnt 6 P g
Di.udar all new materials for inspection. Applicant understands and will comply with
0yc, . I n all non-point source regulations.
P have read the beard, maeriab requimnenls under Chapter 6,95 of the
California Health&Safety Gale,Sections 25585,25533 and 25534.1 understand that
if(he an[it Jte i
n ly have a tenant,that it is my responsibility lm notify rhe
mcupont of( qui its which must be,met prior m issuance of a Cenificae it
O'ca"'oe Signature of Applicant Date
I All roof coverings Owner lir Itnri,ea ascot Dae s to be Class `B"or better g
OFFICE