00070085 CITY F CUPER'I'INO
BUILODNo DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING MDRESS: PERMI INo,
10370 MANN DR ABLE SEPTIC 00070085
OWN'ER'S NAME: APPI.ICAI'IO B ) T:
PIO GERALD V AND WENDY P 01_D OAKLAND RD #949 �d'ylf�r/2000
IONIi: ' SANITARY NO. CONI ROI.NO,
(408) 377-9990
C a]. ARCHIrECIENGINEER: BUILDING PERMI I INFO
woo
BLDG ELECT PLUNK MECH
I'—I I_I l=1 IJ
¢c
e y j LICENSED CONTRACIOR'SDECLARAI'ION Job Description
7=C I hereby affirm that 1 mo licensed under provision.of Chapter 9("amentia,
I eh 5ctTn'nva H)ml Di - ;3N h,n,IxintXsnnd Irate."nrsscnde and myli"n"` SEWER CONNECTION SEPTIC ABATEMENT
r y E is in fiat force and eRe<t� / �7-7Q 75 1
x C 6 Litto,c Cluny Lic p r ((�/
O a U Date Contractor
n 5 u y diARCHI'Ii?CI"S DECLARATION
1=O 4 1 underxmnd my plain"hull be uwd ere public remNs
" .
Licenwd 1'rolhx"imwl
O n Ian,Ii UILDEIr DECLARATION
vl I M1ercby.flim, I am tempt from the Contmetors License Ww h,t the /
_L Cwhichmilosco, pe(Section]IRISH ' .: d I t Caul 1 y y ny
❑ whchcl c. R ,to Amomm adw,boards,d I,h, repair YII rare
a3 peon I .r,ed I req II coca , r pe troll g J, toteem
(caner 1 dpleti it n p Dion",IDI t tat L 1 (Chapteroe) Sq. FL Floor Area O VaI I•�tt �0
i,mm he ing A is c,,mpI,hceEoon o and he br on l„I the Business ianl Any vi Unlet ,J
ter Iran he is 31.5 bl ran applicant
oral or "osis for ubjmi the exmmcnt to Any Dipterany
of Sectin..7Ehn veanytpplicanlrnrapem,i,subjanthe applicant toacivil penalty
of nm more lbw,fiat n,nmrtd doom.(ssno). - APN Number Occupancy Type
❑1,anowner,nmeproparty.mmya,Wloyceswin wagcn. 0aoo,1vcommcrsation, 32645007. 00
will do the work,and the"Imc,ur,in not intended or ulRred lin side(See.704.
itmincss and Probe...anx Codc:'rhe Cunbm7or'"Lleenne Law docs not apply to an Reglllred Inspections
caner of pommy N'h,i builds or improves thereon,and%he does such work himself 106 — SEWER & WATER
ER
or through his own cmpluyms.provided that such Impmvemanus arc not intended ur
"Timed for sale.If,however.the building or improvementksold within one year of 202 — UNDERFLOOR PLUMBING
completion,the owner-builder will have the burden of proving ded he did not build or
impost finla ,owof"de.). 301 — ROUGH PLUMBING
Cl I,nv owner of the properly,am cxclasi>ely nontrading with licensed cora ustor9 m , 507 — FINAL PLUMBING
trammel the p.jet,(Sec.7(W.Basin."and Prolarsiom Crde:)'n,c Conrancor's
Llange 1 uw d,xa nm apply to an ox ner of prolvicy who hwld"or improves thereon,
and who contract"for such prajeas with a conloucladH licensed pumutnl to dre
Conoacmi5 Lkcn c law. -
01 am eaemN under Sec. .B OF 1'C for this mumn
Owner Date
WORKER'S COMYCNSNrION DECLARAUON
herchY.filum under Ixnitky ol'perjary ore cf the following dcclanalonn:
] I have and will notation a CcNEnne tel'Consent to wlkinm¢ I'ar Work""
Componmtion, an provided for by Section 3700 of the IaMm Code, for the
perinm,nnce of the work for which this permit is issued.
01 have and will maintain worker's Compensetinn ia,w nee,as requbrcd by Section
3700 of the Lubar Cada lathe perl'onn:mce of the work for which this(Icrinit is
ismed.M�j�", kkke/r�'-.SCC cation Insurance canicr!yy��J�,j/y�I
Caricr:�/x' kc—t Policy No.:�'""�F _vO
PERI'IpICA1 ON OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
('this section need not M completed if the permit is for one hundred dollar
(SHXE or IeesJ
1 cabby that in the pedoonmuc of the work for whish do, nnit is hoed.I
shall not employ any l axon in any manner so as to become subject to the Worker'
Compensation laws of California.Dote
Applia'an1
NOfICETO APPLICANT:If,after making this Certificate of Exempllon,you should
h taiaC subject w the Wod.ads Cm tinmxibo,r provisions of the Labor Code,you most
Q O forthwith comply withsuch pmvi,im,or this permit shall be devoted revoked.
Z m CONSTRUCI ION[.ENDING AGENCY
I hereby:dlinn that there Is n comauction lending agency hrnhc performation
Lr2 of the work far which this lermit is i...ed(Sec.N197.Civ.C.)
0. C Lendcr's Name
D Z Lcnder's Addwxs
U Q I cenify dim I have read this application and state that the above inform omi is -
Las F Omwa.1 agree ter comply with all city and away ordinances and state laws mlating
Q U tohaddiag eomourtion.and hereby m,nnrire representative.s oflhis city to more upon _
the dewe- cndamicd property'Ila rp
inspection pnnses.
�,� y m(We)agrcc insave,indca,niryand keep harmless the City of Gtpenino against 1
V1 liabilities,judgments,toms and sheaves which may in any way Occur ugainsl suit '..
U Z City in"n",pente of the grunting of this permit.
APPLICANT UNDERSTAN 5 NDWII CO PI 1'�H ALL NONPOI T Issued by: Date
SOURCEREGULATE
SignawmnrnPNieuolc V Date Re-roofs
IIAZARDOUS MATERIALS DISCLOSURE
Will the appbcan,or home buimin......ona"ase ter handle hi,adoa"matelot Type of Roof '
as defined by the Cupeniou Municipal Cade,Chapter 9.12,and the Ifeallh and Safety
Collo,Section 255RD1:'
❑Ye" All roofs shall be inspected prior to any roofing material being installed.
Will the applicant mrom •bulldingncamantn"eequipmentordevi«"which If a roof is installed without first obtaining an inspection. I agree to remove
emit hmardom air annaminams as del incl by the Hay Area Air Quality Manugcn,e ,
)"Id", all new materials for inspection. Applicant understands and will comply with
oY°s o all non-point source regulations.
1 have read The haaNnm materials requirements under Chapter 6!15 of the
Califon la Ilwhh&Safe,,Code.Sections 25505,25533 t 125530.1 understand that
if the building does nm carcn,ly have a tenant,that it is my rc"ponsibility to notify the
occu ant of the requiren rc whish moot he ran prior to a Certilicn -cf
v%lunvn
O'c c •r 0(( Signature of Applicant Date
ox e o aamodam ag�• Da,Date All roof coverings to be Class •'B"or better
OFFICE