03080036 CITY OF CUPEWI'INO "' "x°i .-7-r7777,77,77777777777777.a
BUILDING DIVISION PERMIT aCONTRMATIONN-
BUILDING ADDRESS: PERMIT N0,
03080036
It NAME: PERMIT ISSUE DATE
;PHONE: SANITARY OL NO.
ARCHITECUENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
joo LICENSED COWMACTOR'SDECLARATION Job Description
�+ 1 hereby affirm that 1 Am licensed under provision.of Chapter 9(commencing
with Section 70110)of Division 3 of the Business and Professions Code,and my license is
'q Z_ in full fame and effect.
License Claw Lic.A BATH T U1
6
Data C'S racuir
DECI- ,4 I 1 I — )
ARCHITECTS DECLARATION / I' t
I l understand my plan shall he used as public records ` �I)
360
u.t; Licensed Pnsfeseiunal N'
OWNER-BUILDER DECLARATION
<P 1 naso affirm the,1 case excmpl from the Contractor's C's License Law for the `
❑O followinguirs a Penin lIDLABusinessmp Improve,
deiuns Code:Any city or county
Sm in which its requires a permit to cdres th L acme impmsuch Marlin or repair any structure
in ,hat hpnor e itsissuance,pursuaso nt
totcuhovisio sof for Contrarmit mice se Lawduaument
pm< ,hut he ms licensed pSectio 7 the of Division
of the sBusi est License Lew(ChapterY Sq. Ft. Floor Area ValUat O
t F� (c-1 he is tramming withhereioto,and o(Diasis f r of Al eged Business Any
Code)or
��$ Net he u acmpt therefrom end the buts for Ne alleged eumpdon.Any violation of _1C;71q1nn nn
Section 7031.5 by Any applicant for A permit subjects the applicant o a civil penally of APN Number Occupancy Type
not mare than rove hundred dollen(S500).
Ito ownerof the the
imuct oris employees with wegunale(sect compenmion,
will dothewons end the he Con is non,LicensoLaw dos for apply.7o 66.Business 101 - FOUNDATQ�d Inspections
and property
h ebu Code:The venmcmm,License Lew does not apply lf an owner of
ownenywyceatimovilds or impmvcslherconenmentsA notimssuch wdarlork drfferedmulfor hmughhis 102 - PIERS
own cmptf.
6.buil building
ori prove ant iswmenuemnet ear of�mplcoed future. r. 103 — UFER
huweveethe have
rden improvement ishtdedid one year of completion.the Owner. _
builder will have the burden of proving the,he did not Wild or improve for puryose of 104 — REBAR
A ).
I,as owner of the p opacity.am exclusively contracting with licensed commors to 10 5 - ANCHOR BOLTS
constmn the pmjcct(Sam.7O14,Business and Professions Code:)The Convector's Li. 106 - SEWER & WATER
cense lawdw not apply men owner nrpropeny who hoods or improve thenen.and. 202 - UNDERFLOOR PLUMBING
who convects for such projccu with a contractors)licensed pursuant to the Contractor's
License Lew. 203 - UNDERFLOOR MECHANICAL
Cl I am excmgi ondrsAs._ \,B,&PCfar q. seen 204 - UNDERFLOOR FRAME
�_ UN Allo
WORKER'S COMPENSATION DEC�IM ATION 205 - UNDERFLOOR INSULATION
+ Ihereby aRrmunder pcnallyofperjuryone efthefollowing declarations: 301 - ROUGH PLUMBING
' plheveand will maintain a CeniMmeirCansenuo self.insum for WortcrsCmn,n. 302 - TUB & OR SHOWER
Ration,as provided for by Section 3700 of the Labor Coda.for,he performance of the 303 - ROUGH MECHANICAL
work for which this permit is issued.
❑1 have and will maintain Worker's Compensation Insurance,as required by Section 304 - ROUGH ELECTRICAL
37W of Ne labor Code.for the performance of the work for which this permit is issued 305 — FRAME
My Workers Compensation Insurance carrier and Policy number art: 306 — HOLDOWNS
Cartier: Policy No.:
CERTIFICATE OF EXEMPTION FROM WORKERS' 307 — INSULATION
COMPENSATION INSURANCE 308 - SHEETROCK
(Thissecdonnecd nothecomplewd ifthe lcrmitis foronchundreddollars($10) 309 - EXTERIOR LATH
nr less)
I certify that in the performance of the work for which this permit is issued,I shall net 310 - INTERIOR LATH
employ any person in any manner an a to become subject o the Workeri Compensation 311 - SCRATCH COAT
Law s of Celifemia.Dam
Applicant 313 - ROOF NAIL
OTICE TO
caur
Ncorm..j APPLICANT.theWorIL eller making thisovisio,of of Exemption,you you..., 501 - FINAL ELECTRICAL ENERGY
become subject y the Woher'R Compensation provision,Sh&l of,de labor Code,you mus,
.JZ farmwimcnmplywith Such pmasianarthi.p milahauxe seed revoked. 502 - FINAL PLUMBING ENERGY
�� CONSTRUCTION LENDING AGENCY 503 - FINAL MECHANICAL ENERGY
[r
1 beirchy affirm that them is A construction lending agency for the crformance,of
C 504 - FINAL BUILDING ENERGY
Y the work for which the permiss
it is Wood(Sec.3M.Civ.C.)
w q Lenders Name 505 - FINAL ELECTRICAL
=z cnderIArfify 506 - GAS TEST
V I certify Nu 1 have mad this application and Ruu Nu the above information is
correct,I agree to Comply with all city and county ordinances and state laws relating to 507 - FINAL PLUMBING
o
building construction,and hereby authorise mprosenutiven of this city,o enter upon the v above-mentioned property for inspection proposes FIN MECHAN CAL
C (Wc)eg,tt to save,indemnify and keep harmless the City of Cupcnina against 9 FIN /
fq liabilities,judgmeau,costs and expcnscswhich may inany way accrue against laid City G/
U to consequence of the granting of this permit. SZ — G
^' APPLICANT UNDERSTANDS AND WILL COMPLY WITH.ALL NON-P INT Issued byrr Date
SO EREGULATION
0 ` II Re-roofs
I ore of Wpim..017ommeour Gem
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will the applicant or future building Occupant store or handle hrnrdous materiel
As def ned by the Cupenino Municipal Code,Chapter 9.12,and tic Hcaith and Safety
+da,Section 25532(¢)? a� All roofs shall be inspected prior to an roofing material being installed.
El Yen bklNe P P Y g g
Will the applicant or future building Occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
emit hazardous air contaminants ass defined by the Bay Ams Air Quality Manngcmem all new materials for inspection.
District?
O
❑Yet
1 have mad the hmardnus materials requirements under Chapter 6.95 of the Califor.
niaHnl"SafelyCOM,Scedmu255O5.25533wd25534.lunWr dthuifthe Wilding
docs not cuocndy how a imam.Nat it is my responsihiloy 0 nobly the axupan,of dw
require envwhicItsentieMCIf j .uweeljZfieabofOceuP Signature of Applicant Date
0 ser authorized agent D All roof coverings to be Class "B" or better