00120027 cl uulo" N UI DIVISION
NO PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PF.RMO'NO.
2?=.61 KENDI_E ST 00120027OWNACS bi h APPLICATION ICK
CL /2000
DONATU
ZONE: SANITARY NO. CONTROL NO.
7 ARCHH'EC'l IIiNGINEER; If1111.DING I'IiRMI'i'INFO
oo
w RLDG IiLF.CT PLUMB h1EC11
z LICENSED CONTRAC DR'S DCCLARNHON Job Description
O Z 4❑ I hereby affirm that I am licensed tinder proo siotn of Chapter 4(commencing
wintsectah mxxn an)ivi,imt3tif the nalxnhe�nnn rrtife,xitits Cale.Imdmy license .
a,imm�mmnnn�efry•t r SHAKE TO TILE
z Liccnx CW._((���.,y��q. Lie.N 73'Q A�
F'�d Dale/J.1,51,p� C'ontaLARAIL10,
o(^ / sRcxm[crs Decl.aenn(-,.977
so,'] 1 understand my plans shall M vad ax public record,
u o C Licensed P..lesslonal
ff OWNER-BUILDER DECLARATION
I lurch ilrmt nun 1:I Inln rrmtl nm C....soon,L.een.e Law far the
F 5�' fnllnwing n ..Spoion 7031.51 uad 11 less w Code:Aay uhy o. ninly
aN
F Qp
which nvltiir<n a permit m a,netmct,all<r,Aimpmvn.nelvnlialt.m repair any slmetnre
pathic itscensedarwtrett,tk-eapp,ns(,fcC(,nl emaunitl<axigne(ChapLmm - .
— thanenciii,wah Seaam ntlhe pnwnhmsar the camnaane.ucemclaw lenapter9 Sq. FI. Floor Area Valutftl�QQlt
lenmmenemg with therm 9axn of he basis 3 ohne alleged
and i n.Any vi Cak) 121CI ILf Ise
lir that he is exempt therefrom it,h send the Fusin for the alleged a Ifiali It'Any violation
of Sc,tion 7031.5mIl'y any dP..I doll❑sr a pamait whjecu the npplicum la u civil pcnuhy
aomt htiare titan ave bandaa amnt..(sa)t). APN Number Occupancy Type
❑I.ux ownerof lhepngetiyornty cmployces with wagc.ass lheir sole conipennmion. •52613104. 00 '
will Jo the work,and the amcmre is not intended or oBiml lir sale(Sec.9144,
lluviness and Pridcssinm Code lLe Contrecal Liccnu Law does not appy ,,an Required Inspections
owm:r nrpmpeny Who haul lir improve,thereon,and raw d«n such work hbmdf 305 — FRAME
or through his anon emphgces.provided that such impmvemems are not intended or
offered frenula.If,however,the building or impmvcmcnl is sold within one year of 307 — INSULATION
ion,the owncnildwill have the burden of proving that he did nol build or
improve nnpinr-bcr
ep
nmpn.col al<,l, 601 — ROOF TEAR OFF
❑I.a,nwoer of the propedy,ave exclmauly contracting with licensed unnramom to 602 — ROOF PLYWOOD NAIL '
notrucl the project(Sec.ID-04,Busine.s and Professions Cale:l The Contractor's
Lice nxlaw Jacsnntapplytnannwnerufpmp ywho M1uildsorimprovesther n. 603 — ROOF BATTENS
sena rano
e,ammefor m
en projects with a contractors)licensed pununthe
Contractile,License law. 604 — ROOF IN—PROGRESS
111am ,nln
unto S«. .B ffi P C for this ren.nn
Owner Umu /
WORKER'S COMPENSATION DECLAHA'rbN ` 2
I e r,byand Quinn under penalty of perjury ane sethe following n, for tWt)r
Ih ..willmaintainCbl n f3 It It' f W khe /
pcmfrs r : provided f by S•ci 191x1 sheLabor Cods, 1 the '
fi f tl work f Ii1 t':pe t 1
Olhave not lwill ndou N k Compensation I : -pi,cioelbyS fon
1701 of the Labor Code,for the Nrommince of the k tor which ths crim,is
sued.My W..Uri,Compensation Inw reme carrier and policy number are.
mer:Avgq policy'Na.:CP_P_� 6+7
CER II'ICATION OF EXEM PTION FROM WOR KERS'
COM TENSA I'IUN INS U RA NCH
(Thi,woion real not fe,,or Il,ed id'the permit is far enc hundred dollars '
($1000 or Ic,s.)
I cenify,hut in the po fommnre of the wad far which this permit is i...ed.1
shall not employ any person in any manner.o as us become subject to the Workers
Compensation Law,of California.D:IIC
Applicant
NGIICE TD APrI.ICANT:ICN'aernmking this CcolEcamof Iixmnption,you 4 aid
become sm Jwrla the Worker's Cunlpensidom pmvr.ions of the Emir Code,you Inmt
(] Q li n,vith comply with such prneinia ,or this pemtil sbu11 he declined revoked.
F :0) CONSTRUCE ION LENDING AGENCY
a + I hereby alum that there i%;i construction leading agency for the performilow
of the work fret which this pemhit is issued(Sec.3119],Civ.C.)
Loader',Name
PJ" Lender',Address .
U C) 1 certify dim 1 havcrcud this tmplhvtiun and mate thus the above halnnnation i,
W E., correct.1 agree it,comply with all city and county ordinances and state laws Mining
C U to huilding construction,and hereby authorize representatives ofilik city to enter upon -
} n: the ab ve-mmntioned limitedly fur in.peaion purflow%.
r1 Over agree Io save.Incroulyand keep harmllthe City of Cupenino against
W liahilitics,judgmems,costs and espemes which may in any way le me against said
U r�
Color con.cqucl¢e rel the grmling ul Ibis permit.
APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT
Issued by: Date'
SO u :all) n.°".`c• re y:
Si lit coravpl, moor time eco Re-roofs
IIA%ARDOUS M,V BRIM S DISCLOSURE.
Will the applicant or future building acupam store or Kindle ltamrdme,manned Type of Roof
;is deputed by the Cupcnmo bmicilnd Code.Chapter 9.12,and the Health anti Safety
Coda, cl 2x5321a17
pYes . �1 No .
All roofs shall be inspected prior to any roofing material being installed.
Will nheahplicantin fmambaddho, Men,ant tiso uipmen,or devices which If a roof is installed without first obtaining an inspection, I agree to remove
it hazmduus air conmmina .dcGned by the Bay Arca Air Quality Management
�,�.tdety all new materials for inspection. Applicant understands and will comply with
MNo all non-point source regulations.
Iase al the h aterials requirement%under Chapter f )s ifthe
Calfiforni.,I lealkh r SaKly I S - :2ss1, 125534.I unde,,ti J thl
if,he fallen,ho,v u— Iyl 'trl,flat
it 11 my a '(it aC n the A
rcuPanl al the rtqu �e�h rah sh Dasa M act prior e,issuance al a Cen I tole of
o. y' Signature of Applicant D: e
v. �we8D
r Winer ser aathanr<a agent Dam All roof coverings to be Class"B" or better
OFFICE