03070160 CI'T'Y OF CUPER'1'INO x "t"-k r»s< ;u-• " �+ - '� v,
BUILDING DIVISION PERMIT n,CONTRA-, ,OR NO It
BUILDINGADDRESS: J- b NITE ARNOLFO N AND REBECCA '?"TNO03070160
2200
IER'S NAME: PERMIT ISSUE DATE
NITE ARNOLFO N AND REBECCA F T Q4/21/2004
PHONE SANITARY NO. CONTROL NO.
ARCHITECTIENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
o p LICENSED CONTRACTOR
under
DECLARATION
w 1hendn,ion70affirm,hot 1amlicensedunderprovisionsofCAapmry(commencing Job Description
=W with Seclion]tlfgpnfDivisiun3 ofthe Business and Professions Code.and my license is
n mu force and erf"` SFDWL-2 STORY LIVING 3 , 745
t2_Z License Class TSD a
c_o Data Contractor GARAGE 609 SQ FT
£`- ARCHITECTS l k TS DECLARATION
�y W u I unticrsanJ my plans shall he used as Public acnrdv
coy Licensed Pmlcssirnal
S OWNER-BUILDER DECLARATION
ON
ZOO 1 nasoereby affirm that 18M exempt s anrom the Contractor's Liccnx Lew for the
.fw0O followingreason.a (Section]onstr Buster, and Professions Code:Any city n,county /
mLL which its issuance.
also Il,,Ams the
improve,h permit file
e a airsigned
anystructure
poor mits issuance.alxu mymres the aPPlicam for such permit flea signed suxment
ESG
that he is licensed pursuant it)the provisions ofthe Contractor's License Law(Chapter 9 Sq. Ft. Floor Area V 81
a� (commencing with Section 7000)of Division 3 Of the Business and Professions Code)or
y 3 that he is exempt therefrom and dm basis for be alleged exemption.Any violmion of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of APN Number ' O
not more roan five hundred dollars(S503). 35608045 . 00
ccu pane y Type
❑I,at owner of the pmperty,or my employca with wages as their sole compensation,
will do be work.and the structure is not intended or offered for sale(Sec.7044,Business
.it PrefsSmns Code:The Conuaew'.Liccnx Law docs not apply to an owner of Required Inspections
property who builds lir improves thereon.and who does such wart himself or through his
own employees,provided that such imprrvcmcnts are not intended or offered for fair.If.
however,be building or improvement is sold within one year of completion.be owner-
builder will have the burden of proving Nat he did not build or improve for purpose of
sale.).
91,as owner of the property,am exclusively contracting wish licensed contractors to
tore,the project(Sec.70m,Business and Profeiumax Cud.:)The Contractor's Li-
..law dmf not apply,o as Our of property who builds or improve thereon,and
who contracts for such projects with a reati etor(s)licensed pursuam to be Contractor's
Liccnx Law.
❑lam em P. file,See. ,B&PCfo thisrc on
, Dam y 0,
WORKER'S COMPENSATION DECLA!;AT PN
I ercby affirm under Penalty of perjury ore o(thc fetbGor dwlarations:
[]I here and will maintain a Cenificale of Consent to self-Insure for Worker'sComPen-
sation,as provided for by Section 3730 of the labor Code,for the Nsfa mmwe Of the
work for which this permit is issued.
I have and will maintain Worker's Compereadon Insurance,as required by Section
37M of the labor Code,for be performance or the work far which this Permit is issued.
My Workers Compensation Insurance cagier and Policy number am:
Cartier. Policy NO.: _
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
(This xetirn need nm bs omaidexd Bribe Permit is forme hundred dollars(S IIX)
r less.)
1 certify that in the performance of the work(or which Nis Permit is issued,I shall not
employ any person in any manner on U in become subject o the Workere Co rlogogirn
Laws of California.Dox
Applicant
NOTICE TO APPLICANT:IL after making this Ceni ficate of Escort prion,you should
become subject to the worker's Com pc nsmion provisions of the Labor Code.you must
z forthwith comply with such prnvigri.of this Permit shall he deemed mvoked.
z'O CONSTRUCTION LENDING AGENCY
F" Iherehy affirm Nal there is a eonstrvction lending agency for the Performance of
C(i the work for which this permit is issued(See.3(y/].Civ.C.)
I37 Q Under's Name
az Lender's Address /^
O Q I certify shat l have mad this application and vox bar the above infonnaliun is
ly P correct.)agree to comply with all city and county ordinances and stale laws relining 10 V
0U building construction.and hereby authorise represenutives of this city to enter upon Be
LU
Abovementioned
to ertygive for inspection keep cs.
F a
(We)agree to save,indemnify and which
harmless the City of against against
N in Consequence
enceo the gran and of this"not. in any way accmc against said City
Uz in conuyucncc Of the granting of this P.rmil.
'—' APPLICA UNDERSTANDS AND WI L COMPLY WITH ALL NON-POINT Issued by: Date
SOURCE GULATIO � Ja,,�
q�'J/1/CCo /2 /o
argl,atXncarnppbcanvconL,cx, / , /�/DDaa'te Re-roofs
HAZARDOUS MATERIALS DISCLOSUREV' Type of Roof
Will the applicant or future building Occupant store Of handle hamandm s material
as defined by the Cupeninn MuniciNu I Code,Chapter 9.12,and the Health and Safely
•c.Section 25532()1
❑Yes All roofs shall be inspected prior to any roofing material being installed.
Will thea applicant or mire w lata «er and rte a ai If a roof is installed without first obtaining an inspection, I agree to remove
nn s p q Pmenl or devices winch g
emit haeardnvs air'conmminann u e6nc by the Bay Area Air Quality Management all new materials for inspection.
District?
❑Yes
I have mad the hava,daus materials requircm.nts under Chapter 6.95of be Cali(or-
his Heeldi&Safely Code,Sections 25585.25533 and 25534.1 understand Ihm if the building
does nol correct have a Tenant, al r nsihilily to nrtilY the recap.,of g
Signature of Applicant Date
mquimments ich mug at d e of•ccmq of Occupancy.
_p
r so owed."at Dale All roof coverings to be Class "B" or better