01050071 CITYBILDING DIVISION
P o, PERMIT CONTRACTOR INFORMATION:
ROILDINGADDRE S: • ,t -I • PERMI'I'NO.
'
10605 GASCOIGNE DR ' BUDGET PILINIBI110 01050071.'
OWNERS NAME • APPLICATION SUB DATE
WELCH a ' 28695 'ROANOKE..S'I' .. .05408/2001
PHONE: - _ SANITARYNO. - CONTROL.NO.
(510) 303-7847. .
s OOnARCI Ill ECf/ENGINIiF:R: - o _ BUILDING PEItMI'1'INFO
BLDG'• ELI7CT PLUMB MECH
6 i E LJ O L= CI
Nz LICENSED CONT'RACTOR'S DECLARATION Job Description
z t hereby o0 m that 1 licensed d P ns of Chapter l(oimmcrnl og
m ,withSw o 7IXNp,fD' i I'the0 'n:. II fm.nmCode„ndmylemuc
/is m ii tl force and e0e t t
r. < is Lica WATER,HEATER "REPLACEMENT.
°'0 a U Uam' .Contractor
v1 3 u t] ARCHITI:Cr'S DECLARATION
1 d t J nY nu shall he lewd as public records
OWNER-BUILDER DECLARATION
o c,I hereby affimt that I fun exempt form the Contmnors License Low for the '
1_z following center,(Section 7031.5,Business and Promotions;CodAny city or county
,t pw
which rcy 1 rc:a p rot 1 to con tru t Iter,improve.demolish, r repeir repairany sibructur, '
3C priketuo i 1 s. d rectures,heoppl I to oech,proul,l file a ioned comment
Rod he, been. Ipnr amt their Lu t. fth C mm t License Law(Choptury Sq, Ft. Floor Area - Valuation
n
mintomnng i,th Secfon 7f1001 or Div s on 3 of the Hm o .a
. nd Pn tensions Cade) ,
or that he is exempt d¢,eform and the basis for the alleged exemption.Any vicha o t _ _ _.
of Section 7031.5 by tiny applicant for it permit subjects the applicant to a civil Penalty
of not mem,han me hundred dollars n5I)0). _ APN Number Occupancy Type
01•.,aiiwncr of the property,or my employee.with wages as their solo comp es"i';n, rf
will Jo the work,and the structure is not intended or offered lin sale(See.7044.
Busmen:red&ofcxnionx Care Me Counselor's License law does net apply to an .Required Inspections
owner of ppeny Who builds or inipmves thereon,and who does such work himself
or
11 gh his 11(y provided that such improvereents'ne, t intended or
fl III(I 111 III , sill II' Yci-if` ”
n npl i t Ecowneoholde,willl lh hundur.otpcovin,thot h JJ no,build nr -
improve for Plurnme if I ) '
GIa%twitter ofthe property, exclusively contracting withlicensed contractors to
omit ,the p Iere(See.711411 .' dProfessions Cod,)Th Corincit n n 4
License i d o c'pllyt - f property whe builds 'nIn esbi t.
I h ... E f r such p Sorts wTh m
nvacgs) d.pursuunt t tle -
Codirector,License I w
01 in exempt under Site B&1'C for this reason
Owner Date s V
WORKER'S COMPENSATION DIiCLARATION
I hereby rf min under penalty if perjury one of the following declarations
Cl I have and will mainmin a Cedificam of Convent m elf-insure,for Worker's ,
Compensation, as provided for by.. �
Section 771X) (if the Lorne Code, For the ._
s .
crf,nnansc of tho.work for which chis nnii i.isnuul.
01 have and will redoubt Worker's Compenemlon Insurance,a%up iced by Seninn
3700 of,he Labor Code.for,he performance of,he work for which,his permit is - -
sued My Workers Compensation insurance comer and Policy number are:
Carrier: Policy Nn.:
CERI'1PICATION OIs EXEMPTION FROM WORKERS'
COMPENS/O[ON INSURANCE
To,seniors need not be completed if the penis is for one hundred dollars
($100),,lens) . _ I - II.
.. . o ,.
I cenify that in,he performance of the work Air which this permit is issued,I
shall not employ any person in any manner so as In became subject to,he Worker:
Compensation Lawn of California nine
Applicant I I
NOTICE TO APPLICANT:If,aflei Inking this Cunllierm of Hwinnion,you should
(ices r,objecdbade,Workee!,Ci... rnsatlon provldnnsol'ihe 1,cl Cudc.y,).,,i oI i.
�'Q forthwith comply with such primninns or this permit shall od deemed revoked h
(, V1 w CONSTRUCTION LENDING AGENCY
1 hereby affirm dead them is a construction lending agency for the pnfonnance
Wof the work for whicli,his permit is Iss,md(See.3007,Civ,C.) -
lende's Nrmc 1
Z Lender's Address
V 0 I cenify dou I have ount his upplicnion anal oma,hate uMrve infnmlmion is
�*• F correct.I agree to comply with oil city and county ordinances and suue laws relating _
0C.7
:it building eonamnion,end hereby unhaut,mpresematwesnf Ibis city to enlenipon -
',1 W Die nhbvelnentionnl prol,eny for iusj rctinn purposes
(We)agree to alive.indemnify and keep harmless the City of Cupenino against .
Z) liabilities,judgments,costs and expenses which may in any way accrue against said
City in consequence nfthe grarri.,oftbi,permit, .. '
APPLICANT.UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ISRLICdb - Dale
SOURCE REGULATIONS. y
Slgttatum„fAipficartlCoetmcte, Date Re-roofs
HA7,%RDOUS MATERIALS DISCLOSURE
'
Will due applicient or future building occupant store on handle humblous nurierial Type of Roof
as defined by the Culnnion Municipal Code,Chapter 9.12.and the l leal,h and Safely ,
Calc,Suction 2.55326,7 ,s
1:1 We, 0N All roofs shall be inspected prior to any roofingmate rial'being'ins4dled.' • '
Will the applicant or future building,ccuprm use equipment ler devices which If a roof is installed without first obtaining an inspection,'I agree to remove
it hamir ewro minmis us defined by the Hay Area Air Quail blanugemen
l i, t
• Pordour a
Post I" all new,materials for inspection. Applicant understands and will comply with
°vi °N. all non-point source regulations.
4 1 have,read the buzardous nomrials requircencels under Chapter 695 of the
sc, California Health&Safety Code Sections 2550525533 and 255341 understand that
if the building Joe%not comedy have a tenant,that it is my responsibility to notify the -
cupant of the requircmmats winch must be me,prior to issuance of a Cenifiece of
.. Gcehpancy. - - -
Signature of Applicant. Date
ownnnrarrnndrmasent Date " -AIL roof coverings to be Class"B" or better
OFFICE'},
CITYBILDING DIVISION
P o, PERMIT CONTRACTOR INFORMATION:
ROILDINGADDRE S: • ,t -I • PERMI'I'NO.
'
10605 GASCOIGNE DR ' BUDGET PILINIBI110 01050071.'
OWNERS NAME • APPLICATION SUB DATE
WELCH a ' 28695 'ROANOKE..S'I' .. .05408/2001
PHONE: - _ SANITARYNO. - CONTROL.NO.
(510) 303-7847. .
s OOnARCI Ill ECf/ENGINIiF:R: - o _ BUILDING PEItMI'1'INFO
BLDG'• ELI7CT PLUMB MECH
6 i E LJ O L= CI
Nz LICENSED CONT'RACTOR'S DECLARATION Job Description
z t hereby o0 m that 1 licensed d P ns of Chapter l(oimmcrnl og
m ,withSw o 7IXNp,fD' i I'the0 'n:. II fm.nmCode„ndmylemuc
/is m ii tl force and e0e t t
r. < is Lica WATER,HEATER "REPLACEMENT.
°'0 a U Uam' .Contractor
v1 3 u t] ARCHITI:Cr'S DECLARATION
1 d t J nY nu shall he lewd as public records
OWNER-BUILDER DECLARATION
o c,I hereby affimt that I fun exempt form the Contmnors License Low for the '
1_z following center,(Section 7031.5,Business and Promotions;CodAny city or county
,t pw
which rcy 1 rc:a p rot 1 to con tru t Iter,improve.demolish, r repeir repairany sibructur, '
3C priketuo i 1 s. d rectures,heoppl I to oech,proul,l file a ioned comment
Rod he, been. Ipnr amt their Lu t. fth C mm t License Law(Choptury Sq, Ft. Floor Area - Valuation
n
mintomnng i,th Secfon 7f1001 or Div s on 3 of the Hm o .a
. nd Pn tensions Cade) ,
or that he is exempt d¢,eform and the basis for the alleged exemption.Any vicha o t _ _ _.
of Section 7031.5 by tiny applicant for it permit subjects the applicant to a civil Penalty
of not mem,han me hundred dollars n5I)0). _ APN Number Occupancy Type
01•.,aiiwncr of the property,or my employee.with wages as their solo comp es"i';n, rf
will Jo the work,and the structure is not intended or offered lin sale(See.7044.
Busmen:red&ofcxnionx Care Me Counselor's License law does net apply to an .Required Inspections
owner of ppeny Who builds or inipmves thereon,and who does such work himself
or
11 gh his 11(y provided that such improvereents'ne, t intended or
fl III(I 111 III , sill II' Yci-if` ”
n npl i t Ecowneoholde,willl lh hundur.otpcovin,thot h JJ no,build nr -
improve for Plurnme if I ) '
GIa%twitter ofthe property, exclusively contracting withlicensed contractors to
omit ,the p Iere(See.711411 .' dProfessions Cod,)Th Corincit n n 4
License i d o c'pllyt - f property whe builds 'nIn esbi t.
I h ... E f r such p Sorts wTh m
nvacgs) d.pursuunt t tle -
Codirector,License I w
01 in exempt under Site B&1'C for this reason
Owner Date s V
WORKER'S COMPENSATION DIiCLARATION
I hereby rf min under penalty if perjury one of the following declarations
Cl I have and will mainmin a Cedificam of Convent m elf-insure,for Worker's ,
Compensation, as provided for by.. �
Section 771X) (if the Lorne Code, For the ._
s .
crf,nnansc of tho.work for which chis nnii i.isnuul.
01 have and will redoubt Worker's Compenemlon Insurance,a%up iced by Seninn
3700 of,he Labor Code.for,he performance of,he work for which,his permit is - -
sued My Workers Compensation insurance comer and Policy number are:
Carrier: Policy Nn.:
CERI'1PICATION OIs EXEMPTION FROM WORKERS'
COMPENS/O[ON INSURANCE
To,seniors need not be completed if the penis is for one hundred dollars
($100),,lens) . _ I - II.
.. . o ,.
I cenify that in,he performance of the work Air which this permit is issued,I
shall not employ any person in any manner so as In became subject to,he Worker:
Compensation Lawn of California nine
Applicant I I
NOTICE TO APPLICANT:If,aflei Inking this Cunllierm of Hwinnion,you should
(ices r,objecdbade,Workee!,Ci... rnsatlon provldnnsol'ihe 1,cl Cudc.y,).,,i oI i.
�'Q forthwith comply with such primninns or this permit shall od deemed revoked h
(, V1 w CONSTRUCTION LENDING AGENCY
1 hereby affirm dead them is a construction lending agency for the pnfonnance
Wof the work for whicli,his permit is Iss,md(See.3007,Civ,C.) -
lende's Nrmc 1
Z Lender's Address
V 0 I cenify dou I have ount his upplicnion anal oma,hate uMrve infnmlmion is
�*• F correct.I agree to comply with oil city and county ordinances and suue laws relating _
0C.7
:it building eonamnion,end hereby unhaut,mpresematwesnf Ibis city to enlenipon -
',1 W Die nhbvelnentionnl prol,eny for iusj rctinn purposes
(We)agree to alive.indemnify and keep harmless the City of Cupenino against .
Z) liabilities,judgments,costs and expenses which may in any way accrue against said
City in consequence nfthe grarri.,oftbi,permit, .. '
APPLICANT.UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT ISRLICdb - Dale
SOURCE REGULATIONS. y
Slgttatum„fAipficartlCoetmcte, Date Re-roofs
HA7,%RDOUS MATERIALS DISCLOSURE
'
Will due applicient or future building occupant store on handle humblous nurierial Type of Roof
as defined by the Culnnion Municipal Code,Chapter 9.12.and the l leal,h and Safely ,
Calc,Suction 2.55326,7 ,s
1:1 We, 0N All roofs shall be inspected prior to any roofingmate rial'being'ins4dled.' • '
Will the applicant or future building,ccuprm use equipment ler devices which If a roof is installed without first obtaining an inspection,'I agree to remove
it hamir ewro minmis us defined by the Hay Area Air Quail blanugemen
l i, t
• Pordour a
Post I" all new,materials for inspection. Applicant understands and will comply with
°vi °N. all non-point source regulations.
4 1 have,read the buzardous nomrials requircencels under Chapter 695 of the
sc, California Health&Safety Code Sections 2550525533 and 255341 understand that
if the building Joe%not comedy have a tenant,that it is my responsibility to notify the -
cupant of the requircmmats winch must be me,prior to issuance of a Cenifiece of
.. Gcehpancy. - - -
Signature of Applicant. Date
ownnnrarrnndrmasent Date " -AIL roof coverings to be Class"B" or better
OFFICE'},