01070035 TINO
C sun DING DPERONPERMIT CONTRACTOR INFORMATION:
B ILDING ADDRESS: PERMIT NO
0713 LARRY WY 01070035
1�1�'I NATHALIE J TRUSTEE Aa7L'TN �0A01
PHONE: SANITARY NO. CONTROL NO.
1
nt0 ZO ARCHITECT/ENGINEER: BUILDING PERMIT INFO
�y BLDG ELECT PLUMB MF.CH
G 6 te CI I= 1_""1 CJ
< LICENSED CONTRACTOR'S DECLARATION
so
I hereby aRum that l am licensed under provisions of Chapter 9(commencing Job Description
with Section 7000)of Division 3 of the Business and Professions Code,and my license WATER HEATER
6 m h is in full force end eRect.
c z License Class Lic.p
n O a O Dene Commcmr
3 a}n ARCHITECT'S DECLARATION
1 understand my pli ns.aholl be used us public records
�T
I°dd 6 p Licensed Professional
OWNER-BUILDER DECLARATION
u'f I hereby aRrm Nat I am exempt from the Comractnr's License Law for the l -
(_? following reason(Section 7031.5,Business and Professions Code:Any city or county $800
zF G which requires a Permit to construct. Iter,improve demolish,or repair any smactute
tat 3 .P t t q th ppl cam for cucM1 peon a fl g ed stammem - -- ------ --
that heigl ed pr ram dro,rovismasoftheContmcm.LceneLw(Chapmr9 ,- '31IOFdO@14bf'9�ar Valuation
i n egwthSection7000)of Denson 3 at the Business and P (esslons Code) ���)-�f 4� l0 In 4x, sr ta
or that be m exempt therefrom and the bass for the alleged exemption Any violation
of Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty -
ofnot mom thanfivehundred dollars(s5W) 502A1'-tN.P1QT2_pg 72krUMEMN or
ERGY ccupa[ yType
❑1,as owner of the property.or my employee with wages is their sole compensation, 506 1 GA s SE T ? (� � I�
'INxin ghproperty
e work,Y anios aw provided
no Com intendoar's ice .5catLaw
for sole(See 704,1 � s t, _-,.L. I ---
B s n as a d Protean ons Code The Contractor's L L d not apply to ,1 507', F I T bT s C Ions'_ -1
neo of ron Who Ids or ten roes there n and who encs encs work himself s 1t
or through his own employees.r,tv din th t. ch improvements not intended or
:cooffered ion,the If,er the building t r'mproemelt a sold he did one year of
completion,the owner-builder 11 have the burden of proving that he did not build or I
improv rr puryme of sale.).
canr of the progeny,am earlBusiness a contracting ux Cast
The
h contractors to t License
the project(gee. too owner
and Professions Code:)Theves themon, - -
- License law does not apply to an owner th property who builds or improves thereon,
.and.who contracts for.such projects with.a contractors) licensed pursuant to the
Con tors License Lew,
❑1 emptor err nw B&(P'CCf/oj�thh mason
Owner s Dam v - n rr rir
RKER S COMPENSATION DECLARATION -'—�^
1 hereby aRrm under pc.try of perjury one of the following declarations:
❑ 1 have and will maintain a Cenlfcate of Corneal to sd6insure for Worker's
1. Compensation, as provided for by Senior 37W of the Labor Code, far the
performance of the work for which this permit is issued, �.
❑I have and will maintain Woiker'S Compensation Insurance,m required by Section
37W Yuba Labor Code,for the performance of she work for which this permit is
Issued:My Workefs Compensation Inmmnce artier and Policyroadsters.
-' If
OF EKEMFf10N FROM WORKEKS'
Cartier. ..o} � I....fi r.Policy No.: ' •'? .: '� . r--r• � ^ri .� n1 - .... '
COMPENSATION' 11 INSURANCE'• _---..... ... .- ..__._
__... _..__._.._.. _ �. -_...
f n" si. ctiliti need not be complete)if the permit is for one hundred dollars I 1
($100)or le'".)
1 certify that in the perfomlance 6(the&ark for which this permit is issued.l 1
is hall not employ any is rgon in any manner so res to bicome subject m the Warkeos '
Compensation laws of California.Date,
Applicant
NOTICE TO APPLICANT:If.afmr making,this,Certificae of Exemption,you should
0 O become subject to the Workers Compensation provisions of the Lubar Cou ode,ymost
forthwith comply with such provisions or this permit shall be deemed revoked.
CONSTRUCTION LENDING AGENCY -
� > Ihereby affiron that construction lending agency for performance
of the work for which this .it is issued .3097,Civ.C.) "
Q Use
Name" '-• .. _. ... . .. _. ._ . .. ._ .
r7 z Lender's Address' .. _ .t•,
V0 I certify that l have mad this app It c unionand state that the above information is
taa E. correct.1 agree to comply with all city and county ordirard nam laws relating
0.�t..) t building c nstructon andhereby artaze epr S mtiv .s of ity to enter upon
r� the abe mentioned p perry fo inspection p tp
try 2. (Wt)agree to save,indemnify and keep hurtle''the Cry of Cupertmooganst
h
.w' liabilities,ludgmems,cons and expenses which may in any way accme against said (( /
U �.e City in consequence of the granting of this permit.
^ APPLICANT UNDERSTANDS AND WILL COMPLY WITH ALL NON-POINT" Issued by: Date
SOURCEREGULATIONS. t y
Signature'ofApplicanscmamclo,, iDate Re-roofs
.,. HAZARDOUS MATERIALS DISCLOSURF. -
.. „ NII the'applicant o future
building occupant store o s die herallous tart nal 7)rpe of Roof .. .. - .,
as defined by the Criterion Municipal CWe Chapter 9.12 and the Health and Safety 'at •- 'II LI A,
Code.Secure 25532(a1
❑Vas •ONo, 'All,roofs shall.be inspected prior to any roofing material.being installed..
Will lie applicant or future building occupant use equipment or devices which If a roof is installed''without first obtaining an inspection, I agitee to remove
emit hazardous air contaminants as defined by the Buy Area Air Quality Management
Dlatdcc all new materials for inspection.,Applicant understands and will comply with
ores 0 N all non-point source regulations.
I have read the hurardoui materials requirements under Chapter 6.95 ofthe
California Health&Safety Code,Sections 25505,25533 and 25534.1 understand that
if the building does not currently hasn't tenant,that it is my responalbility to notify the -
occupant of the requirements which must be met prior 1.issuance of a Cenifcam of
Occupancy. Signature of Applicant Date
Dwna or authorized agent Data All roof coverings to be Class."B"or better
.• . . OFFICE _._ .