02120037 CITY OF CUPEWrINO
BUILDING DIVISION PERMIT CONTRACTOR INF ^ RMATION: 'I
BUI11067A84ESG,ASCOIGNE DRIVE PERMITS®2120037
QWtFR]S Ti1E FRI TS INGER APPLICATIPNlM5TFY 2 0 02
ONE: SANITARY NO.// 11 / CONTROL NO.
ARCHITECT/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
�00 LICENSED CONTRACTOR'S DECLARATION hI,pp pp p
hemM1y affi m that l am licensed under provisions of Chapter 9(Commencing REPLACE SEWER -FR riC�U JE
with Semon 7100)of Division Sof Ne Businessand Prommu des Calc,trod my license is
Fpy mfnu rnrcJxan�(erfay ,Z� �� �^ /_�. S TO SIDEWALK
Zoo/,? Lkenu Cl Lk.' t4f— ° y
O p Date Conu��acIy
FHtl ARCHITECTS%LRATION
rc< 1 unajtd my plans shall k used as public records
Id
w3a L'acnud Pndessional
OWNER-BUILDER DECLARATION
zq I hereby affirm that I am exempt from the Contractor's License law for in,
i t:0 O following mason.(Sccuun 7031.5,Business and Professions Code:Any city or county
Wimports,$� whichqa permit m amsuua,aItm improve,demolish,or repair any structure 3 6 0 0
Fiy prior to ie issuance,also requires the applicant for such permit to file a signeJsmlement
t< that he is licensed pursuant to the pmvisionsof the Contractor's License Law(Chapter 9 Sq. Ft. Floor Area Valuation
g (commencing with Section 7&X)of Division 3 of the Business and Professions Code)it
w R S Nal he u exempt therefrom and che basis for the alleged exemption.Any violation of 37529043 . 00
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number Occupancy Type
not mom than fiw hundred dollan(S5(101 106 — SEWER &- WATER
❑ I,as owner of the pommy,or my employees with wages as their sole compensation,
will do the work,and the struaum is not intended or offered forsale(Sec.7W.Business 202 _,�
and Professions Code:The Commutes License Law does not apply to an owner of 30,
— ROUGH tJlvt eC IOns
property who builds or important Better,and who denssuch work himselfor through his p.
own employees,dieea.ping or Imrwchimpsawmenaarcne ear of
dor meTercd for talcs.If. 5 FINAL "PLUMB
ING
huilder .meavetiebrimprovement ismldwiiinot year of completion,theowner.
of a 1; .x �l
builder will have the burden of proving thus he did not build or improve for purpose of ,
sa)e.).
❑1,as owner of the property,am exclusively contracting with licensed contractors m
consumer the project(Sec.7144,Business and Professions Code:)The Contractors Li-
cense Law does not apply to an owner of property who Index or improves demon and
who contracts for such projects with a contractor(s)licensed pursuant to the Contractors
License Law.
❑ I am exempt under Sec. .B&P C for this reason ` l
Owner Dam
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations /
1 haw and will maintain a Certificate of Consent to self insum for Worker's Comped
sation,as provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
Q 1 have and will maintain Workers Compensation Insurance,as"cited by Section
3700 cef che labor Code,for the performance of the work for which this permit is issued.
My Worker's ompensation Insurance cart.m and Policy number are:
oder: } r, oliR N 7 80
CERTIF AT OF (EMPHO WORKERS'
COMPENSATION INSURANCE
(Thisuctitm need not k completed ifIk permit is forsme hunJmd Jollam n la)
to mic.)
1 cenify that in the performance of the work for which this permit is issued,l shall not _
employ any person in any manner art as to become subject to the Worteri Compensation
Laws of California.Dam
Applicant
NOTICE TO APPLICANT:IL after making this Ceni ficate of Exemption,you should
become subject to the Worker's Compensation provisions of tk Labor Cam,you must
O O forthwith comply with such ponvamns lir this permit hall M deemed revoked.
z CONSTRUCTION LENDING AGENCY
[rr I kreby affirm chat them is a construction lending agency for the performance of
C the work for which this permit is issued(Sec.3097.Civ.C.)
a0 lenders Name
a z Lenders Address
U 0 1 cenify that 1 have rad this application end tam that the above information is
U. F correct.I agree to comply with LII city and county ordinances and sate laws misting to
DU building construction,and hereby authuve repreunalives of this city to enter upon the
W above-memioned property for inspceuon purposes.
41. (We)agree to save,indemnify and kup harmless the City of Cvlxnino against
h liabilities,judgments,casts and expenses which may in any way eccmc against said City
U 4 in conuqugnce of the granting of this permit. (61
APPLICA UNDE ANDS AND WIL COMPLY WITH NO POINT Issued by: Date dv
S URC EGULAT S.
e-roofs
9g HAZARDOUS MATERIALS DISCLOSURE ate Type of Roof
1 Will the applicant or future building occupant store or handle krmduus material
ea d med by the Cupenino Muni al Cum,Chapter 9.12,and the Ilcalth and Safety
C. Section 25532(a)? All roofs shall be inspected prior to any roofing material being installed.
0Ycs No
Will the applicant or future building occupanl use cyuipmeal lir devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hevmdnus eftjCuds, U
defined by the Bay Area Air Quality Management all new materials for Inspection.
District%
E]yes
Ihave real riels requirements umkr Chapter 6.95 of the Cali(nr
.in Health&Solely05,25533 wd 25534.1 undersand that if do hudding
fires not urrcnlly itis my es nsihildy Io bodfy Iks vpomof the
ire ms bmis. cnilicute'If Occup Signature of Applicant Date
w
r andnrxe asenr Dam All roof coverings to be Class "B" or better