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02100031 CITY OF CUPER'1'INO -- BUILDING DIVISION PERMIT CONTRACTOR INF�ORMATIOW Bull-11C TTO SHILLCREST RD PERMIT N102100031 Ow9k1R vNETZEL APPLICATIT"MSY2OO2 ]ONE: SANITARY NO. // vv // CONTROL NO. ARCHITECT/I!NGINEER: BUILDING PERMIT INFO BLDG ELECT PLUMB MECH 0 0 0 0 uo+00 LICENSED CONTRACTORS MOR'SDECLARATION cuF 1herebyaffirmtbut IamIimeBuunderidProemofChapmr9(commencing TEMP POWER Job Description <3 with Smsi,)n]ggp of Division3nf the Business enJ Pmfessinna CnJe, nJ my license is infull furcande n. Lr o z", Data Class Conn.�L 5.', OZ-0 Dam /n%1/ice Controcurt — P/L-f— F=� ARCHITECTS DECLARATION C� 1 undcrsmnJ my plans shall k uxJ es public rccnNs , U m3 a� Licensed Professional H t�0, OWNER-BUILDER DECLARATION se <7 1 hereby affirm that I ora exempt from the Contractor's License Law for the $150 d60o following rcuno.(Scnion]I131.S.Business and Pndessinns CltJc:Any city nr anunly an$E which requires a permit m construct,alter,improve,demolish.or repair any suuawre prior to its issuance.also requires the applicam fusion permit m Glc a signed statement thalhe islicensed pursuant to she provisions of the Contractor's Liecax Law(Cope,9 Valuation (commencing with Section 700))of Division 3 of the Business and Professions Gxle)or _ that he is exempt therefrom and the basis for Ne alleged exemption.Any violation of Section 7031.5 by any applicant for a permit subjects the applicant o a civil penalty of PMN Occupancy Type ammmethurfive hundred aolmrs(s500). 304 - ROUGH ELECTRICAL P y YP C'2.as owner of the property,or my employees with wag.as their elle cnmns peatinn, will do the work,and Ne structure is not intended or offered tarsale(See.7044,Businam and Professions Code:The Conwcmr's License law Jens not apply to an owner of Required Inspections property who builds or emphases thereon,and who daenouch work kmxlf or Nhaugh his / own employs,provided that such imphavemw t arc nm ear ofc m o0ered for cele.If. however.Ne building or improvement is hath within ala year of mprove for the pose of builder will have the burden of proving that he did not Wild or improve(nr putpnx of .Jr.). / ❑1.as owner of the Sec.70propany..Business exclusively ao fessi ns with:)The contrecmrs t. came La the project(Sec.o a 4.wneofand property who Wilds Cale:)The Cs those',) ad cense law dceh not appy to an owner of pmpeny who builds or improves Contra,and who contracts for such pmjecu with a contmcmr(s)licensed pursuant to Ne Contractor's License Law. ❑ 1 stn exempt under Sec./p sty .B&P C/for Nis rcaum Owner ;Y41 /w�Data /,J3 O WORKER'S COMPENSATION DECLARATION 1 hereby affirm under penalty of perjury one of the following declarations: 1 have and will maintain a Certificate of Consent to ttlGinsute for Workci s Campem nation,as provided for by Section 3700 of the labor Code,lou the performance of the work for which This permit is issued. have and will maintain Worker's Compensdion Insurance,as required by Section 90(t of the Labor Code,for the performance of the work for which this permit is issued, My Worker's Compensation Imsumnce eerier and Policy nuntkr am: Cartier: 5;4.�'e Far,I Policy No.: _ CERTIFICATE OF EXEMPRON FROM WOR K ERN COMPENSATION INSURANCE (This section need not k complcwd Ifflue permit is I'nronc hundred dollars(six)) M)axe) I certify that in the perlbm mance of the work for which this permh is istted,I shall not employ any person in any manners,)as to kcome subject n lire Workers''Compaimmoon Laws of California.Dale Applicant NOTICE TO APPLICANT:If,arta making this Ccndi.te of Exemption,you should Become subject to the Worker's Compensation pmvi.sions of the Labor CnJe,you must O O forthwith comply with such provisions or this permit shall k deemed revoked. z ^' CONSTRUCTION LENDING AGENCY _y [-� l tomabywhich ret Ne Nero iseed(Secs3007,lending agency GR tire perl,)rmanceof mai the work for which this permit is issued(Sec.3007,Civ.CJ W� t7 Lender's N.M. .7. z Le der Address U 0 1 cenify that 1 have read this application and smut that she or.inRnmatiuo is [k. F consul.I agree to comply with all city and county ordinances and stale lows ceasing In 0 building construction,and hereby authnnrc representatives of this city I,,cuter upon the W above-mentioned property for inspection purposes. C (We)agree us save,indemnify and keep harmless the City of Cupeni no against Co) liabilities,judgments,costs and expenses which may in any way accrue against said Ci ly U Z In consequence of the granting of this permit. APPLICANT UNDERSTANDS AND WILL COMPLY WITH AL1.NON POINT Issued by: Date O 3 ^D SOURCE REGULATIONS. Re-roofs Signature mf ApplicaO Dam HAZARDOUS MATERIALS DISCLOSURE Type of Roof Will are applicant or future building occupant.Chscore or handle hazardous material as re,Sac by she 32(a)l nn Municipal Cssde,Chapter 9.12.and tk Health and Safety Code,Senium 25532(,))? ❑Yes �[Nn All roofs shall be inspected prior to any roofing material being installed. Will the applicant he future building..pant me equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove 7d.a mit M000dous air contaminants as defined by the Bay Area Air Quality Management all new materials for inspection. istrict? ❑Yes on 1 have read the hamahms materials requimments under Chapter 6.95 of the Califon iafl"llhASafetyCa .Secde.25S)5,25533.d25534.I aWersmnd Nosifthe wilding not amoam ¢ m,N y n' ilityto notify Ik neupam mf the yuirem mnmam n or ,) acemrcamoramp r' Signature ofApplicant Date _ J 5 Owner or ausho' dagent I ale All roof coverings to be Class "B" or better