01030004 CITY]BUIOFNCUPERONNO PERMIT CONTRACTOR INFORMATION:
PERBun.Dmcnrn)Rn s: DON WADE ELECTRIC CO lrrvo 01030004
OWNER'S NAME: APPLICA'1'I0N SUR DATE
16320 HARWOOD RD 03/01/2001 lkms
PHONE. SANI'T'ARY NO. CONTROL NO.
(408)1377-2323
O ac ZAHC111'1'EC I'll?NGIN.IiH: BU1LDMG 1'ERMI'1'INFO
F-,❑6❑ 81.06ELEC'P PLUMB MI'CII
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2 O vuiLICENSED CONTRACTOR'S DECLARATION .lob Description
I hereby nflinn that1 am licensed under provionnn of Chapter 9(cons cueing
w x'ith Section BXXB of Division 3 of the Business and Profeoion.Cut I orP h"re,
cex iscefulle.reeanew=L'n x 200 AMP SERVICE CHANGE
pdu Liansc( Hitt—� Lic.p_
w 3 a h One Camrvcvn
t-a O A CHITIiCr'S DECLARATI(L
g I anderaond in,plans shall he used as mhlic beards
ce s o o Licenwd Pmfevnional '
OWNERTUILLATR DECLARA'1'I0N
I bemby wrrin Ihm I am exmoln From non Commelor's uaemse Law for the
Z< tbllnwiog r, n(Section 7031 5,Huai iced P...fis s Code:Any city o any
F❑ which I'cynlrN o Nook to construct,aller,ahnpmvg dunndish,or repair any stmcmre
n3� prior In its..... c,also re,alms the apnlican
nor such poued lot
nnio Ele a signmw l
Thin he is licenwd pursuant to the provisions of the Comrnen.rs license Law(Chapter 9 Sq. Ft. Floor Area Valuation
(connncneing with San Pon 7000,of Division 3 of the business and Professions Code) _
of Thal he is exempt therefrom and the basis for the alleged exemption.Any violation $0
01 Scmion 7031S by any applicant for a Pennh subjecn the applicant to a civil penalty
of her more than rive hundred dollars($ec). APN Number Occupancy Type
01,as owneroftheproperty.ormyemployeeswithwagesastheirsirecompensation. 37518044. 00
will do the work,and the structure is nm intended or olTatw for sale(Sec.7WS.
Business and Professions Code 'Me Cnnimcmr s License Law does not appy a.an Required Inspections
orvthr ofpropcnY Who builds m improve..thereon,and who does such work himself 304 — ROUGH ELECTRICAL
rough his own employees.nmvidrd that such improvements are inn intended or
o f=red for sale.B;howeve,the moving or improvement is sold within one Year nt 501 — F I NRL ELECTRICAL ENERGY
iumplclion,the or—mr-budder will have ate burden of proving that he did not build or
mprove karsrpme orsalc)' 505 — FINAL ELECTRICA
❑I.: of the pmpenv,um exclusively 111.11.11H.,will:licensed emnmemrs tri
Lmstmc Thpmjecf(Sec.7(94,Ha. and Proessons Code:)The C(nlrucun's
icense I,does not apply in an owner of pnq,eny who huildc m Improves thereon.
mW whit contracts for.such pmjCOs As Ill it cnnlmclugs) licensed pursuant to the
C mmmtnr's License Law.
❑Tum excnlpl under secs .N&PCfor this hawast
Uwncr ENS
WORKER'S COMPENSATION DECLARATION O
1 hereby senior under penally of perjury one of the following declandio., /
❑ I have and will maintain o C,mficam o1 Consent In mlbineum for Worker's
Comscnanion, as provided for by Section 1910 of the Labor Code, for the
perlonoarne of the work for which this senior is issued.
❑I have and will n aintain Worker's Compensalinn In-macc,as mquired by Section
3100 nlIIm hobo.Code,forthe pero...a ce of the work for which Ihis....mins
Issued.My Workers C'on pprnsalym loomane e earlierr and Policy number arc.
Gorier.-�ryrV"VTNr
.S Policy Nrx:/y�W��IH��.
CERTIFICATION Os EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This wmion need not M completed if the permit is for one hundred dollars
(510)or less.)
I certify that in the performance of the work for which this permit is issued.1'
shall not employ any person in any manner sit as u,become subject to the Worker,'
Com,redion Llws of Cali6,mia.Dam ,
Applicant
NOTICE I O APPLICANT If,armnnnking this Cenif icufe of Exemption.You should
necmne.Id,o In the workers Compensation,no,ki.n.of fhe Labor ewe,You mast
,Q O forthwith comply wins such pr isirnls aI'This scoot shall be demned revoked.
CONS'fRUC'I'ION LENDING AGENCY
a , I henchy.Rhin that there is a eonoruction lending agency for the performance ..
it'he work for which this sum it Is issued(See 3197.C'Iv.C.)
0. Q Leodcr's Naim
U Z Lewers,Address
U Q 1 certify that I have read this application and state that the above information is
tz [.. correct.1 agree to comply with all city and county ordinances and stare laws relating
Q U
to building donunuction.and M1cmhy amhorim representatives ofrhi%city to enter upon
} W the aM,vememioned property for inspttaion pugases.
C• y (We)agree n.save,indemnify and keep hamde.s the City of Cupcnino against
VI liabilities,judgmc ts.costs and expenses which may in any way accme against said
U Z City in consequence of the gruming of this permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITHALLNON-POINT n A�/
s n Iorv. �,��Q, Issued by: Date
slgll::f��Ie':'I Ahrue:Iml"`c`IIt,,, Dale Re-roofs
HAZARDOUS MA'I'RIALS DISCLOSURE
W'dl ma alis-am or inane bwdhrg oc,u nl I svnem handle nmardoes tnmedal Type of Roof .
as defined by the Cusen'mo Municipal Code.Chapter 9.12,and the Health and Safely
Code,Section 25532m)1
0 Yea "ro All roofs shall be inspected prior to any rooting material being installed
Will the appheam or future bunking occupant use equipnelt or devices which If a roof is installed without first obtaining an inspection. I agree to remove
emit haaallous air contaminants as def nth by the Buy Area Air QualityManagcmcm
District? all new materials for inspection. Applicant understands and will comply with
0Yes '" all non-point source regulations.
1 hmc rend the hreardous materials requirements under Chapter 6.95 of the
Czliharm I Iealth K Safety Code.Sections 25505.25533 and 25534.1 understand thatif the building docs sol unmanly M1ave:,lenan1.Ilial it is my rexlamsibility to notify Tho
Oxvpam of the mquinnncnts which oma Mone o issuance of a C)))conkme of
Ownpuncy. �
A Signature of Applicant Date
Owner mamnmtael igen, Dal= All roof coverings to be Class "R" or better
OFFICE