00100101 INO
CITY I DING DIVISIONPERMIT CONTRACTOR INFORMATION:
B U ILD ING ADDjIlJD7.2'0 HALE PL PERMITNO, 0010011111-
OWNER'S NILMLEF_ STEPHEN Y AND AGNES L APPLICATION 1il 6 1
h ]ONE: - SANITARY NO. CONTROL NO.
p s z ARCHITEC AINGINBER: BUILDING PERMIT INP -
woo BLDG ELECT III U, MECH
yea
LICENSED that i a COMRACnOR'S DECLARATION
o 5 v= Job Description
O e,y p 1 tionherXB tit that 1 am ofthe B under provisions fe of Chapter (commencing
.rmFu, wdnsr<•tinnngxnn(ni.iso+rJnoneBuainr:;aamfProfe..mnacndearamrmmnae RE—PIPE
se SS IN
In full fmcC an, 1.
COuU License Clgs.J_ Lic. 46
Cond Y -
< n RCHITy ECT S DECLARATION,[
ECLARATION stiseii
I undersB;uW my prom shall Fe used us puhlic records
ae
ant 25 p O Lieensul Prole,imal -
aJ o OWNEna rs'Lla ti n, he ARATION i -
ut1 1111101, B II 1 1 m 1 Ih C 1 um L Law for the
�ZQ following- (S t' "IIlndmll, a attllnf:.' raCdc Ary Trysou,tuty
yy p whirl, It ul t u st Itc p J dish rep nytater re
63^� III t t ,:d the
,I+li tl hp niu II '6cdsrncmcnt
ntutl dpm, n N l tn. til 'r t mr I L' (cbaCor9 Sy. Fl. Floor Area Valu 1
or Out lie 111 c.11 1 henchman
an..Lir Divldmt J of the Biaidlv,ml sempti ra(essy i Code)
Lir that he is 31.5 bt Iany alp m and the nasia fnr the alleged exemption.a ,il alaion
of Section a than
n live hu dred tanl fnr u Penna mnjrdu the applicant ns a civil penalty
Lir nnB imnrc uratic enandren dnna+.lssBt). APN liu04ko0]E.+. 00 Occupancy Type '
❑1,as owner of the PmPeny,ter my employees wish wngcs as Boric sole mmpcnsmion,
will do the work,and the structure is not intended or offercA for sale(Sec.70.1x,
Business and Professions Cuba:The Contmctur's License Law does not apply to an 202 — U Fft- d WRcfWnWMB I NG
owner of prnpi Who Wilds or improves Bhercon,and who does such work himself
or through his on employees.provided Nat such improvements am not Imended or �r�] — ROUGH PLUMBING
uttered for wle.If,however,the building or improvement is sold within one year of
completion.the owner-builder will have the burden of proving that he aid not build or 50$ — FINAL PLUMBING ENERGY
improve fm purls"a of sale).
507 — FINAL PI_IIMBING
01.as moor of the gmpcny,um exclusively commaing with licensed contractor,to
construct the does
(See 7W4.BosBusom proand Professions hCorlLild%or The Cv,Barer,
License Lew d«s nm apply m an nvner of pmpeny who build}m improves Thereon.
and who cnmrecBs for such projects with a commmogs)licemed pursuant 1. he / /
Contractors,License Law
L)Iur .
❑ oexempt under Sec &. ,B P C for this reason
Owner Duro
WORKER'S COMPENSAf]ON DECLARATION O/
1 hereby affum under penally of perjury one of the following declarations:
] 1 have and will maintain a Caf itinne of Consent m Q self-insure for Worker's 1/7
Ccurr nsalion, as powidcd for by SnSimt 3700 or the Labor Cade for the V
performance ot'the work or which this permit is issued. '
❑I have nn I will maintain Wnrker'e C...npermtlon Insurance,as ruluhed by Seaton -
JTBfI oI'the Lnhor Code,lir the per earnance til the work for whleh this permit is
sued.My Workcr's Commcnsndon Inxnreare carrier and Policy number are:
Ter, Policy Nn.:
CERI FICTION OP EXEMPTION FROM WORKERS'
COMPBNSAPION INSURANCE -
(This section need am be c rl,lned if he permit is for one hundred dollars
(Slap or Icss.)
1 certify that in the perfddemoe of Nr work or which)his permit is issued,l
shall not employ any pc n a u,ce to Ne Workers'
Compcnsmin r tfn n�s O
dppPlicvil_
flnflCE PLI A,'CIL Ber ma-t thi. mo(Rxemp,ion,you should
Ohecome sallIRNet to the Worker's Compensation Provisions of the Lahr Cade,you must
fanhwith comply with such Provisions or this permit shall Na deemed invoked.
Z
F' hatrebM
CONS heRUCI'IONLENUMG AGENCY
1 h
' ey M.,hat mere iss construction(Sc. lending a C.) for We perfottnance
of the work for which this permit is issued(Sec.7(191,Civ.C.)
L Q larder's Name
a z LenAer's AJArc.0
V l certify that l have read this upplica,ion and slate that the above information is
13s Fs correct.1 agree to comply with all city and county ordinances and state laws relating
QfJ to building construction,and hereby outarize representatives of this city to enter upon
�^ W Bhe ch B il P P nY l,I,troponod purposes
t„i y (W)agree to India and".7
lanhe y f C t< .nil agumq
h Iimbil B - j Ig Lr, t. d - s h h Y gains xi J
V Z. coy e m k' tg nn 't
- SOPLC rU STb U�LC WITH AL � Issued by: Date
s't
'it nppha.tit tin+m„r tie t? Rc-roofs
IIA.ARUOl1S MAfEItIALS DISCLOSURE. '
Will th'n T”ma ur fnmtn MJlAing«nupunt smrc or handle hazardous mnteritd 'type Of RO
us deEtied by Bha Cupertina Municipal Code Chopter 9.12,and the Heohh and Safety s
Code,Section 2557200!
ore, [2 No All roofs shall be inspected prior to any rooting material being installed. '
Will the applicant tit future building occupant use equipment or deviceswhldt If a roof is installed without first obtaining an inspection, I agree to remove
coil hazardous air mnmminatas as defined by the Boy Arca Air Quality Management
iatnerl all new materials for inspection. Applicant understands and will comply with
❑Yra 0 N all non-point source regulations.
1 have read the hazardaus matcrird,rcgarmarms an Chapter 695 of the ,
California Health h5ufmy Code Semions2555,2553 5J11undersmnd that
if the building does Icufr Live a lent ,that( a hum,ibilit,wromythe
mcupa the r im Ls ah mus, mm I I seuance of a cart ata m
f7C
in Signature of Applicant Date
eror Bud at IFe All roof coverings to be Class "B" or better
OFFICE