00100106 c1Tv of CU1" R two
nuu,1)EN DIVISION PERMIT CONTRACTOR INFORMATION:
xud.HING ADufillo MANN DR PERMIT NO. 001001.06
oWIIER'S NAMPGn RRITY TERRENCE J ET A _ nrl'IdcnnoN Sll,lt'virl].6/,^—_Q101Z1
2r
)Nr, SANITARY NO. CON'I'ROLNO,
3sv mew?•«do
O ao 2 ARCHITECI'IENGINEER: BUILDING PERMIT INIf)
gO O_ E11.1)G, Ei"ECT I'IAh11d MI CH
E �/ O
FZed
HG LICH SED CONTRACTOR'S DECLARATION ,lob Description
i>-o Indrenr mon thalam Ecen.'J ander pm.ia��n.of cM1aplergann,mencing SHAKE TO SAME
mCO wi015emiun 7110(p err Division3 nl'the llu.inansmnlpcife,sism,C ieense
c' is in full force widdd.NM�rr(er. 9 //`V—JDAZ
sC¢ Liocn,c Cl:ns _f
Da1C CnnlfaIlnr�
13 O v ARCHITECT'S DECL ON
°' g 1 understand my plans shall be used us public reennh -
)$r
1 i p C
Licensed I'mfasiunal
'L o that I r exempt from
DECLARATION
I hereby affirm that 1 1. exempt from the Cessions o Lien yc Ire cu the
my
whnwire moc,is(Section co.o .cher.and Pro..c.dennali Calc:Any city or amnry
to
which 4 Ili era 1 t p Is p J fa.r p' y.( lord
x
a3. prior lr t Inru1 it p�I nsvf M1pc ilmflsignedttmem _
that net licensed putimeamI he poo lor,or he Cami Ueeme Law(chapter 9 Sq. Ft. Floor Area Valuap9T'00
(commencing w'nh Section 7000)of Division 3 of the xnsine s and Professions Code)
or flout nc is caempl tberefrun and the hulls fur,h,alleged exam,inn.Any violation
of section 710]1.5 by any applicant for a Pernitsubjecu the applicant to a civil penally APN {u Occupancy T e
m nut mare than rise material donao.(s5W) NMV.9003. 00 P Y yP
❑1.a,owner of It,.grope ll or try employees will,wages a,their sole cn.o,v,atlon.
will do the work,and he ewcour,ie not intended or i dored for sale(Sec.7W4,
Business and Provision,C(or:The Contractor's ucco,e I.aw doe, la apply to on 305 — FF. jured Inspections
owner of progeny Who builds or improves thereon,and who does such work himself'
m through his own en In,.........ded mal.ndr Iniprrvcmcnl.,are hnemled or 307 — INSULATION
uttered for sale.If,howdver be loading or improvement is sold within one rear of
connpletion,lie nwner.hailder will have tine boman AIrociog(I,o he did stn mold or 601 — ROOF TEAR OFF
imp r..efor pemo.cof.als.). 602 — ROOF PLYWOOD NAIL
01.x.owner of the pmpcny.am exclusively contracting with licensed contractors to 603 — ROOF BATTENS
consumer the pnjccl(Sec.70o.du.iucss and 11.'ofx.ian.C., I Ila,Contrucmr'n
Licence Law Jr es not npply to an owner of property who builds or impm.es therm.
.ad It.eonlmel,liar such pmjllll wioI a toolmelar(s)licensed puraoanl to the 604 — ROOF IN—PROGRESS
Conmictors License Lm,
01 at,,esennpt under Sec. .It k P C to,this renmo
timer Date ,
WORKER'S COMPENSATION DECLARATION
1 hereby allimn under penalty of Perjury one of the lollnwing declarations:
, IM1 J ill 1 CertificatefConsent I If I N kers
comp i' jac,illed lor by S,,tio. 300 of the [..hot Cads. to, he
'Ifiallamee ii,heweek fill hch his parmito I...N
❑Ihave d ill maintain Worker's Cpca 1 hismarae,as requiredbvS inn V
3700 or the Labor Code.I' II peilormance ol'th k for h h this p. 'i is - 0
.sued.My Compensation Insurance uamer and['cities actitiver.�ou /}(� f;')
X ComerZIWV�ICAI(l
f XPolis
EM.Nn _Lf WORK LKS /t 6 l/
' OP[%IiMi'fION PROM W'OHK CRs'MPENSATION INSURANCI?
hi. edot M completed d the pdnnit k for one hundred dollars
IS
[1111)or
Ic+.l
I cosily Ihm in the peri not of the wok for which this permit is issued.I
.hall not employ any person in any manner m as In become subject to the Worker.
Congomaion Lowe of Cdifonde.Hine
Applicant
NOTICE TO APPLICANT.If,star snaking this Certificate of E.ennption,you should
h,,moc objecuo the Workers Compensation powiliom of the Labor Coke,you mus
Q Q Inrthwah comply will "III pmvWit nsonhis pcomil,hull bedeenmd revoked.
7_
Vi CONSTRUCTION LENDING AGP.NCY
1 hereby affirm that there is a Conome ion lending agency lar the penom,a ce
of the work for which this Penni,i,1...cd(Sec.3017,Ci,C.)
0. p 1<alia"Name
G Z Icndcr's Addres,
C...) C) 1 certify that I have read(his application and stairthat the alawe inferrmt n is
s t.. correct.1 agree to comply with all city and county ordlnarce.amd Nine law,relining
Q O io nuildr,c n,Waion.md broby.authhisdmnt
nriae representatives oftty ecruprm
W the ahrvomenfamd Pmpeny lot inpceilon purpose,.
�`•y ky IWe)ngrceto save.indemnity and ktxp harmless the City of Cupanino against
h liablli(ioJudgmene,ceras and P°rod,which miry In any way nccruc againa said
V .Zs Ciiy in cnnxnpscncc of the glen •of this
APPLICANT UN L•R ND NO WILL COMPLY WITH ALL NON 01 Issued by: Dal[[e
/ SOURCE REG
S.
/7•\ sisn:oareor pNidan 'ontrl o� ae Re-roofs
IIALARD()US MA'1'1?RIALS DISCI.OSIJRE
WJlthcopplicamartumremsildingrecupanlstomrnhamdehazarJr .tin risl Type of Roof
m defined by the CupeNno Municipal Cade,Chapter 1).12 nnJ the f eolilt Aril Solely
Crile.Section OYo, 25532(a)7 polo
All roofs shall be inspected prior to any roofing material being installed.
Will the applicant ormtummiding m'cap^ntuse climPmcntIt device,which If a roof is installed without first obtaining an inspection, I agree to remove
mit h oaolous air com:nninarts ser defined by the Bay Area Air Quality Management
,I.lridl., all new materials for inspection. Applicant understands and will comply with
13 Yes 0 N all non-point source gulations.
I hove read the hazardous materials requirement.under Chaplet 695 of the
California Health ist Satny Code.Scc(imu,21505.2553.1 ad 25536.1 undromol thus —
ifthemoildingdoc,notcunentlY ^tenant.Aha it is snymsplvsdolily to notify the
<opani of ibc re Sk be
ism perm m is,uoatc of a Califscme of
asap ands Signature of Applicant Date
ownerm net
od,m ! Date All roof coverings to be Class"B"or better
OFFICE