00100127 CITY OF CUPER'I'INO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRP-SS: PHRMI'1'NO,
22,-:1'74 Iff C:I._F. I...I...AN RD AQUA rFK Pi ll1"lFI,l,l,lf3oura' , ; ' >'
OWN'ER'S NAME: AI'1'LICAI'ION SUIT IIAl E
GI"I.I.I: I._ITII.7 7.1 L.. 1- ':' : R 1 :'
1'I IIINP: SANITARY NO. CflN9R01.NO. -
❑ce Z. ARCHIFECIIIiNGINFIiR'. RUILDING PERMIT INTO
BLDG ELECTPLUMB MECH
Z Z' LICIINSED CON'IRACIOR'S DECLARATION - Job Description
''L w' I hereby altirnt Ihul I ant licensed antler Pru...inon nl'Chapter 9(ewmne x,ir,
,nl-,• w ith Section 7000)of llivision 3oflhe Bust....and l' m,;,i,ms Codd.and nI,license
in ce f,r<c a e 7s�7 �
�an< i;irn.c�ss max 3 fit:'I ':I:f'E:/I)OMIi_S'T':I:C CUP'-'F'LF
C h Uwe �4nKCIB'n:ct"s of CLnNnA'1'HTNN-
5 1 andcrstwa,,,y pmnn.tau M aaen to rtmm record.
ec
o 0 1.i,onmd rrme..a,..ul
ofE OWNER-BUILDER iRDECLARAIION
roti =' 1 herby u(fmt that 1 1. emmpt fmtn the contractor,C's :A n c taw for the
fillhalF7 which'ingam,.mason (Section)031.5.I.alter,impose,
deinnaCNet Any city nrcounty
s$
which reya re.a penoa In ennamel.Aller.ilnnrnYc aflnuh[n.or
3 pd.,ru,i,,,isa,na,al.,mymre.me:.ppucatn mr.n<n re . . alm<mrr
ka rr,,dt m,nlr:I ....d
swannml
mat heialicensed pnt,Noma the pn,v„inn.nftire Contrada'sLicense Law(Chapter 9 Sq. FL Floor Area /3 Valuation
monimenci are with Section]0110)of Division 3 of the Business and Professions CNq
or that he is exempt therefrom and the basis tut the alleged exemption.Any violation
of Seel 703I5 by any npplicam h.r a"c"al subjects the uppllc:au 1". ,,it Penally
of manna count file hundred dollars x500). APN Number Occupancy ype
111.a,,.act,fine pro,o:y,or my employees with wages.,'heir sole compensation. '4142
.
17u 00
wrl do Ira work,and the onsb rc is itended or altered tor Bale(See.]Ild-1, -
If
'
holiness alta Ilmressi,lrs Cade: :he C.mirnncor's Lilense Law mes no,apply I..,n Required Inspections
owner of propny Who builds or impm.rs thereon.and who duels such work himself
or through his own employees.provided that such improvements am not intended or � __ 13
EWER to nmol a:how r,aur building o ,.pro est is sola within,c year or :I.O6 ek_WI:=Fi & WATER
e.c r i .ern n r
c.....pled,,.the owne,h:ime,will have[lie burden ofpmvingthallie did not kaildor UNDE:RF•L_00R P1._LIITIT;:I:ISl(31
Improve for purpose of 4e). ....
C1 1,as owner of the pol,scity,arn lochoosly commeling with licensed contractors :301. ROUGH Pl_UITIBT.lo
mtlmc,the nmjert(Sr,.Jana,points,..al ProR,.„n.C1, he Contractors ;1302 R -.. T UD & OR e)1-10Wli:.R
License Law does nut apply h,an owner,,pmpny will)builds or improve Ihmacm. /
and who contracts for such pnjcct%with a contmmons)uan.ed pursuant to flat ,'-.02 ' ' F1:IdAL 1-'LUITIE3'ING ENERGYcoumarins,Liceme Law.
°I am exempt umle,Scc. .Bas VC aur ml.rcaom ',1506 — GAS TEST
owner Dale 0/9/ 9 50*7 1-1NAL PLUIT1E)ING
WORKER'S COMPENSATION DECLARATION
I hereby aainn under I<Italty of perjury are or Ire following dovda..tln...',
O I have:codw`ll maintain a Cenificatn of Cnmcnl to soll-in.ure far Worker's
C....p I p s d d 1 r b11 Section 3700I the Labor Cede, for the
Orf, III k forwhich 1 .loonalit I
°1 base and -II maintain Wdukt compensation Insurance.to required!by Section
3700 of he I,bau Code for he effornamme of he ork far which this pool i.
ca,d MyWdrku,Cn p oon...t lawauxe arri,ranallatey mardo,ram
carder: policy
o.:Nn
CERTIFICATION OF pE .: FROM WORKERS'
Cot be
IduN INSURANCE
(This on neral not h rnn,pineJ it the Penni.is Icor one hundred dollars
(SI W)or Icss.l
I certify Ih:n in the perfainnnce of(ad work for which this hermit is issued,I
shadl mol e,,,,I,y any person in any manner s)a,In become sobject ,,,he Workers'
Compensation Laws of California.Date
Appleton
NOT cli TO APPLICANT:L1:alter making thd Cmllieam of 17x......on,you should
hceomsubject m the Worker's Compens:ni,n pmvoi.......t me Labor Cam,You must
Q O Ic bnhwl'h comply with soca P I,,Wiens or his Pani(shall be deed,..l revoked.
z _
ti CONS'ere is a ION LENDING AGCNCY
1 hereby wiliest the, m ,Ia issued ed. Icn.ling agency fur the perf......anm
of the svod,tin which this pont,is issued(Sec.Jfp],Civ.CJ
LiandaL Z 1.ad,r's N:m,e
� Z
Pander's AddrC>.i
U I mnily that I hive read This application and stale that the Ossa,ialbrinalian is
correct.I dorm to comply with all city and county ordinances and slate laws relating
t) to building conuruclion,and hereby muton,mposenl:niVeS of this city to enter upon
r W the nlieve.Tmn il)net proTed,Ihr...."lion pmpnws,
6s (We)agree to save indemnity and keep harm less the Cityof Cnpn inn againvl
4 liabilities,judgmenu,colo and exposes which may in any way accrue against said
U Z City in conw,menccof the grunting of this Nero,.
APPLICA NT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT Issued by: Date
SOURCE REGULAI IONS. y
Signature If ApphcantlC,nv-.w,r Dale Ro-roofs
HAZARDOUS MATERIALS DISCLOSURE
Will the arp.icn.nu,trial.h,imiag,an.pnI I.,m„handl,na,ardou.mmenal Type of Roof
as defined by[be Cupeninu Municipal Code.Charred 212,and The Ilcallh and Safety
Cede.Section 25532(:)^. /
°Yes 5!No All roofs shall be inspected prior to any rooting material being installed.
WiJ the ap,h,ant l)r comm b..i ldi,tg..reaper l..c v,Ni,asrd dc,ica.whmh If a roof is installed without first obtaining an inspection, I agree to remove
emit 40 haeardouv air ennlamiamic as Js•tried by the[fay Area Ai,Quality Managcmcm
Dintn<l. all new materials for inspection. Applicant understands and will comply with
°Ya° N” all non-point source regulations.
I hole read the hmardou.materials reyui,nnems under Chapter 6.65 of due
California(.garb k Safety Cede,Section,25505,255]3 and 25534 1 undmmnd that
rhe building docs not currently have a mnam.that it is my ruspm.ibilily to notify the
i)cpda.Pmn of do m,uomntcO*Irwh most be the trio, Mato a red of as niEcee or
am
y T�y r -
Signature of Applicant Date
ownmaanm,d,rJ:Ige Dam All roof coverings to be Class "B"or better
OFFICE