01030116 CITY OF CUPE RTINO - -
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: _ PERMIT NO. '
6701 JOHN DR BUDGET PLUMBING
OWNRR'S NAM(_,: - APPLICATION SUB DATE
GRAVENHORST, HENRY. AND PONA 58695 •ROANOKE ST 03
SANITARYNO. - CONTROL NO'
re0 G ARClll'I ECI ENGINEER: - _ - . , BUILDING PERMIT INFO
``F?2 BLDG ELF.Cf PLUMB.• MUCH,
F Aye _ Cl CI I—I C7
z S = LICENSED CONTRACI OR'S DECLARATION Job Description
-
Oz_; 1 hereby affirm that 1 am licensed under pmviiions of Chapter 9 frommlereiof I p -
P=C N with Section 70Dm.q Division 3 ofthe llnsinas and Professions Calc,and my license
< is in full force and effect.
eana< LieemecDs: k WATER HEATER -REPLACEMENT '
C M V Dale Conimem
MG
pt<s ARCll rc I'SUI:CLARATIONr - F'N A LC� r
�J I J .t any pl : Iluall leln. plhd: a /�G G! 1 -
'm p�' Lt II f:, al OWNER-BUILDER DICIARALON .IAN 1 Lt 9000 -
13 I hereby affirm Thal 1 a n exempt Gn n the Contractors Cttna Law fin life V- 1 O L L ,
s-z< following remnn.(Section 10315,Nusinna anJ Pmfex,inns Code:'Any city or coumy -
F O whifh requires a pennil to consul ober,improve,demolish,or repair any nmcmre. -
�u3v, Four o its issuance sko requires the applicant for such permit o file a signedstmcment
then he is licensM pursuant to the pmvis ono of the Commetor's License Low(CMptm 9Dor Arel Valuation
(commencing with Section 701D)of Division 3 of the Business and Professions Codel
nr'hat he is exempt increment and the basis for the alleged exemption.Any violinist. _
of Section 7031.5 by my applicant for u permit subjects'Inc applicant m u civil penaltyA La
idi more ban five initial d.nan($50U. - - APN Number•' ,. Occupancy ype
❑I f thppcn3,.nn5 allployeati 'th vajes as their sole ilra,adlm v i :' •. .
will to I rk and the slumme is nor intended off,ins!for:al Iscs 7041,
Polio a1 PrR"lar,Code IbeCrt urs Lala Law does Ofq'plyian " Requlred,Inspectlons
-'of pn,ro,Who M1uddn ur intprnva Ihfrcoit,and who docs such work IF It d
It -
,it through tuition employes,provided nuIlilt imended'm 204 — UNDERFLOOR FRAME
1 offered fur sale.IL however,'he building lir improvement is sold within Inc year'it a
completion.the nwimr-builder will mic the burden of proving that he did not build or - n3j01, — ROUGH PLUMBING
,mpinve for purpose ofsdeJ. -
01,a,wmirof the pmp'ny,amexew,iolycontracting with tieenuaamtractonm 303 — ROUGH MECHANICAL
Cnmwct the project(Sec.7614,Business and Professions Cooll The Comracml s 304" — ROUGH ELECTRICAL -
aidwhocnse wdracsforsuhpojownera,acamywho iliceeedpursamatrices tnereontotW 505 — FINAL ELECTRICAL
Ga who contracts far such pmjmts.wifh a nmwmorty licensed pursuant m the i'
�ll.lmClllls License Law. '
❑I ma exempt order See. ,B&P C fionmF riasort 507 — FINAL PLUMBING
Own" Date FINAL MECHANICAL .
" : ..
WORKERS COME I NSAI ION DECLARATION ARATION
urreby a if.oder family fNj.ary n Id. fB gat 1 t , f 5114 -' FINAL .PUBLIC WORKS
❑ 1 have slid will refintain a Ceti fiaa of Consent to self-immone for Worker's
s '
Compensation, as provided for by'Section 3714 of.the Labor Code, for the - -
perfinmanceoftheworkforwhich'hispefmit is issued.
❑1 have and will maintain Worker's Compensation lmumnce.as requital by Station
3714 of the labs Code,for the pemoulance stf the work for which this permit is.
issued.My Worker,Compensation Insurance Gamer and Policy number are:
Currier: Policy No: I-
CERTIFICATION OFEXEM19'ION FROM WORKERS' wi
C'DMPUNSADGN INSURANCE .. - ,
I'I'his wolon need not he cobngrmtl it the po'rood; "for one littered dollnrs,
i$Pill or less.)
-1 cenity that Ia the performance of the work fur which this permit in issued,I -
shall not employ any person in any manner wo as m become subject o the Workers
Compensation Laws of California.,Data
Applwum
NOI'ICETOAPPLICANT:IB ager making thisCmi(icnfe of Exemption.you xhnulJ -
because subject m the lotodcfmlr
s Cnbsainn,ockinns ofthe labor Cad,yon tons'
Q p fun his ith comply with such provisions or this proof shall M deemed rcroked. `
z .
'CONSTRII,it ons facts NG AGENCY
a + IIICrfby which'his lemali:I Cnnld(Sce. 097,.gag C.) far IIIc pcd!all.illlCl• ,
I I F, which n ' Ire ISae 30n cv.c.f ,
r N Lal4 .Addnsc
V Q I cenify Inds 1 have oval this application and sone that the above intonnmion i,
W t•`
correct,I agree to comply with all city find county ordinances and Stam Incas relating
0 C.7 to building Construction,and berchy authorize representatives of this city to enter upon "
�,I W the zbovcumetnioned pull for mo,oion .pm,now
F y (0.'q agree m sl too...ify and keep harmless(be Ci'y of Capen,n..,.am,. ,
rn liabilities,judgments,costs and expenses which may in any way account agn,nst said '
V z City in consequence of the gnmling of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-PAINT Issued by: - -Date
SOURCE REGULATIONS,
S,aamu of nppi,canUContmflur - Ilam Re-roofs `
HAZARDOUS MAI
hMAI'QKIAI-S DISCLOSURE
W' lhelpIn'edal - Type of Roof
.mdermadhy' cacunf' I lrul Inn-um nth el 1'. :
per) mMl.rpilC,vm .
1 -
Chanter912,and the llwlth and Sul sty t
C.I.,Son 12.1532(.)2 a ,
Oyes ❑Nn I All roofs shall be inspected prior to any rooting material being installed.
Will the applicant or future building acclaim use equipment or delices which if a roof is installed without first obtaining an inspection, I agree to remove
em„moodous air contaminants as critical by the Bay Area Air Quality Management a
District? all new materials for inspection. Applicant understands and will comply.with
I 0Yet 0Na all non-point source regulations.
1 hate read the hazardous nmmriuls requirements under Chapter 6.95 of the '.
California
Uchida&Sublet,Code,Scctiom 25505,25533 and 25534,1 understand that
Fin,building does not currently haven tcnfint.that it is myrespmisihility ,,unity the _ ,d
accupnnl of the regnlremems which Innst he met prior m source or Cruilicum of
oocupn.cy. .
Signature of Applicant Date
4 `
Ow.erm aathodned agent - •Date All roof coverings to be'Class"`B" or better`
OFFICE �—