02050118 CITY t DING DIVIISSIIONNDPERMIT CONTRACTOR INFORMATION:
Bk1ll,plryLiygpDRMPERIAL AVE ACME & SONS SANITATION/E P�` I 02050118
CTX'Y I ' WOODROW 3408 HI-LLCAP AVE `ff� TyjbU2
PHONE: (408) 295-2263 SANITARY NO, CONTROL NO.
O 0 ZZ ARCHITECDENGINEER: BUILDING PERMIT INFO
m(r BLDG ELECT PLUMB MECH
�<6 LJ -I T-'T -1
LICENSED CONTRACTOR'S DECLARATION
z y Z 1 hereby affirm that 1 am licensed under rovisions of Chapter 9(commencing Job Description
gN_q ra p r ( g TEMP POWER POLE
-h with Scc,1on] )of Divisian3of Ne Businos�(nd Professions Cwk,and mylianse
m I is in full fo and n. k7C1
o w u Ism
a Lir.p
6 V Cont Lta
a O✓n ARCHITECT'S O) A 10
} 1 n rstend my plsns:hall be used as pub c records
7 p O icems,man -
OWNER-BUILDER DECLARATION
" I hereby affirm that I am exempt from the Contractor's License Law for the $500
y
follom
F-•Z0 which
a SalliPermit
tn7(IILS, t.that,irnrom,deolih,ae Anyrmpi cityntructuy
o wh h q r n perm n o t t alien mfor such
demolish,or rtpav ally mm�urc
Q ..
prior t t coal req prit to the pr pions o far f the ContramutmfleaLicense luoe(Catemem -------
(commenting
__..
(cothisnt 51 nwiotdthSe Section
nonsn3oftheaaftora9miP,rl.asions odeter ,.3. 214.Cg}t5x.�f.�a:p�l , Valuation
or n g thSefto 7man 6fDivisiono the
Bu{Inesgnl Prokn ons CodeE •i i .�,kk_ p �tr^y,l '( l '
or that he s 31.5 b,the, pli and the basis for alleged exemption.Any violation)r.hy '
Of Section7031.5than llanyapplicant(orapermit subjects the applicant too evilpmahy
� of not more then Bvc hundred dollna($500). 10 3APN N&fi&r :cors`ac` Occupancy Type
❑I,asowneroflhepropsny,armyemployesswithwageaadmiTsolecompensation, 304 - ROUGH ELECTRICAL
will'do the work,aad'the nmemre is noriolmded or offered for sale(See.7614: - - •1
;will
and Professions Code:The Contractor's License Law does not apply to an Required Inspections
caner of progeny Who builds or improves thereon,and who does such work himself
oohed fi his own employee.provided that such veanav-"-Id are nos imm�dW or
�bRemd"loisale:IL hbwevci;the building of imp _i.-.— y I ,rl
vff,...to t d within one year of fI�� ��
improve for the owner-bale.)`will have the burden of proving thin he did nm mild ar �a e�A "' ""
improve for puryme of sale.). e'!0
❑1.aslmmes of the progeny,am cxclus vely comracung with licensed Lommctorsm MAY 2 8 2002 -- --- - 3 , ' .
4. Ltinsthe protect(Sec 7(UL Business and Ponfess msalc)CThe Cmum,um s ,i ,
wu cense Law does not apply to an owner of property who builds or improves thereon,' s `
._ _ contracts for.saeh projma with a ca omenorfs)licensed pursusat to the_
end who
Cwntt❑lam exc T
Dora r License ,
mgt tiers' i ' ; B&PCT`this rtasan g�I1 ���G. .)t �:k'/'t
0 some - .. . 6
)� WORKERS COMPTNSA ON DECLARATION
�• Thereby affirm under penalty of p:Bury one of the following declarations: ...
El1 hAve mid will maintain a Ceniftcam of Consent to selLinsurc for Worker's
Compensation, as.provided for-hy Section 37W of the Labor Code, for the
- - imrfomance.(tne work for which this Permitil issued.
❑I have and will maibmin Workers Com}icniatiun Insuronce,as required by Section
its e M CF.RTIFICATItlN.OF ene c of th-walk for which this permit's
3700 of the lab r Cade to,,
o the perfo qqq
ttn ranee +�end Polly be arc:.
t EXEMPTION FRO O RS _ I 5 , If. - >
„ COMPENSATION INSURANCE __.
i iGhlrs x6cnnn aced rani he dxtirj,e'd if the permit is for one hundred dol un ��• "''- ''`r -r t••- ', ,1 i(
($10(fior Icss.)
l emfyy any the pert Tape f r work for which a ecl lis Issued'1 -
C II of bmplay any 6f alio In any mann r sd os,o Ixrome sub)en tolneWakcrk' " ' r
r
Compenza,ion Laws of California,Deie
:If
nprovisions
... .e
- - - - ------ - -
._ . ._._
NOTICC TO APPLICANT If after
mak gNsCrtfcae fExcpt...... h Id
hewsubjecto the Wok isC mpcns t p n'of the LabCode, run
Z fnh ,h cam Iywith h ro isions or this penon hall be d red rvoke . ..._ -.,_
_..._._..
_
> 'CONSTRUCTION f ENDING AGENCY ' a' L'
;
a, Ili ray firm that theret' t'conslending agency for the performanceK
- '
nl the work for which : ..
Nis perm t is issued IS 3097,Civ.C)
.Ledtt N ..
Leatlr Address
V' I cenfify that I have mad this applacautonand state that thbo information
LT. [.. m n I grc t o ply with all city end county d rad...a,1 s rclat ng
C,V mbmldmgconstmcuon,and hereby ouNonze iegresemetives of Wscitymen¢r upon
�] the shove-mentioned progeny for inspersion purposes..
Q. (We)agrcems< ndem'Ty and kap harmlis the City of Cupeninoligems,
FFFn.. Ln liab 1 t ) dg ems,costs end xpensn h ch may in any y ecru galast said p
V Z Cityut sq coca n/the gmm gof the e t n J4 Ail /
"" AP ICA"T UN . STANDS MDN'ILL COMPLY WITH ALL NON-PO fI I �Y/ {/ (�
s L a1I rieaf'—' •( l Z/(T/1 Issued by: Date
ig a' fAPplicunJComma r),'f' - ' '^ Oa e' Re-roofs
'sh ' HAZARDOUS MATEft1AL5 DISCLOSURE .' ".
Will the Ppitmnt m(umrt building occupant n r ha die hainNous
material Type of Roof_ . . .. ..
s d fined EY N Cupcn o M c paPCod Chapter 9 12,antl the Health a d Safety
f I , y
Code Sen nn 255RIa1 /'t t.i t •�t t tt .•t '•'
f.. t r
❑Y o" n
h t'' N
All roofs shall be inspected poor to_any roofing melena] being installed.
wit Ne appncnnto mmeb la go p uae yap t d
at Orrace If a roof Is Insiall edtwithout first obtainininspection, I'a ren
no to'reove
<mn hazardous Imam t♦esd'fned by the BeyA ea Av Quality MSnukement g anP g
o a ftoYe - ,Na all new materials for inspection. Applicant understands and will comply with
6 " all nor-poinf'source raguanons .f..,,. - �u... . . . .
`a+'R' Ilhave imail the h dour m5teriols mquimmems under Chapmr 6.95 cram
Cel(omni Hcelth&Safety Code;Sections 25505.35533 and 25534 1 understand that
Oaitna upantotheer,not quiremntwhic must t-Nnuns to t.mat,ora ennifythe
prat of the rcyuircm1, hili must mt, o to is ofa Cen feet of
y Signature of Applicant Date
- -
.;, G pn�ogxed age , Al] roof coverings to be Class "B" or.better '' ;