01030001 CITY OF CUPF.RTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS; PERMIT NO.
10399 MERRIMAN RD HAMMERSCHMIDT CONS RUC-I'ION01030001
OWNER'S NAME: APPLICATION SUB DATE
TAMARA 1574 COUNTRY CLUB LR 03/01/2001
PHONE: SANITARY NO. CONTROL NO.
(650)948-4200
0 0 AHCHITECUF.NGINECR: BUILDING PPLUMB MECH
ERMIT INFO
BLDG ELECT
V1.I �I 1=1 1=1O
Zy Z LICENSED CONTRACTOR'S DECLARATION Job Description
,Z_ 1 hereby affirm that 1 am licensed tinder provisions of Chapter 9(commencing
with Section 7(X10)of Division 3 of the modules and Profession.,Code,and.11 icense
a a=C is in full force an ct. /i F
fig•L' Lill, cm,yyy��,^yC',�L7� Lia.a_716 •r
til 3`a y Date��� e�p_/_ Cmnmemrl�N.+�
C O ARCHITECT'S DECLARATION 1
S S 1 understand my plans shal l be...d us public recmNs iJ171
tdu
9, Licensed Professional
Pa a OWNER-BUILDER DECLARATION —
u1 1 hereby afPo�m that I um exempt front the Contractor's License Luis for the
(: G fallowing reason.(Section 7031.5,Business and Professions Code:Any city or county
Z O which requires a parmit m ciamtmct,alter,itnprovo,demolish,or repmr any structure
a3$ Pont its issuance,also requires the applicant for such parent no file a signed statement
Nuthe is licensed pursuammthe provisions of the Consultors Li.lntw(Chapter 9 Sq. Ft. Floor Area Valuation
(commencing with Section 700(8 of Division 3 of the Business cad Professions Cade)
or that he is exempt therefrom and the basis for the alleged exemption.Any violation �s1:.01sB0t�t-
o1 Sao air 7031.5 by any np,Lear,font pcnals sabjaca the apsthmm,in it civil PunAty
of not more than Five hundred dolma($500). APN Number Occupancy Type
01,ms owner of the po.,my,or my employees wan wages as that,role ema, amiun. 34229020. 00
will do the work,and the structure is nal intended or offered for sale(Sec.7W.
Business and Professions Coded The Cnntrector'x License law does not appy to an Required Inspections
owner in noperty Who build,,or improves hemma,and who does such work mm elf 101 FOUNDAT T.ON•
or through his awn employees.provided trial such imp nwmneats are not intended or
offica d for sal,.If,however,the building or improvement is sold within one you of 10.2! — PIERS
completion.the owner-builder will have the burden of proving that he did not build or ,7s
improve for purymccol"ale.). 103 — UFER
01,as owner of the progeny,am exclusively cumulating with licensed commalo s no 104 — REBAR
Liinstruct the project(Sec.7044.Business and Professions Cade:)The C...a arm's
cense Law doe,not apply to an owner of property who bonds or improve,thereon. 105 ANCHOR BOLTS
and who contracts for such project with a comuacmgs)licensed pursuant to the
Contraemr,Licarew Law. 106 — SEWERts !i' WATER
01 rm exempt under Sax. B&P C for this reason
202 UNDF_RFLOOP. PLUMBING
OwnerData
WORK HE'S COMPI!NSA'1'[ON DECLARATION 203 — UNDERFLOOR 1YIECHANTCAI,
Ihereby afford under Penalty ofp,rjuryone othe following deelamtmns: 204 — UNDERFLOOR FRAME
0 1 have and will maimei. .Cenifcme of Consent to,elf-msam for Workers 205 — UNDERFLOQR INSULATION
Campt as provided-ter by section 3700 of the Lose, Code. far d„ ^0]; '-- ROUGH PLUMBING
perfanuan.of wr ++
the
rk for this permit is issued,
I have and will maintain Worker's Compensation'Insurance.as reyoimd by Section 302 — TUB & OR SHOWER' .
3 W of the Labor Cale,for the perfomtance of the work far which this permit I, 303 _ ROUGH MECHANICAL
issued.My Workers Com�C` ti Insurance carrier and Policy number am:
Carrier_ }'yrrhey Nu.: _� 1 304 — ROUGH ELECTRICAL
.CERTIFICATION OF BKIIMP'I'[ON FROM WORK 305 -- FRAME n
COMPENSATION INSURANCE y f -) �D I't Y�,
(This union need nm be completed if the permit isfa one huMre olllaca 'kk06 — HQLDOWNS
(sloe>rr Rod 307 — INSULATION
I certify thm in the Iterfamnaum of die work for whah this par it 1,Issued,1 308 — SHEF_TRQCK
shall tint employ may pers+m in any manner so to to hectare subject m the Wnrkern'
Comparator.Taws of Culikmie.Data 309°- EXTERIOR LATH
Applicant
NOTICF.TO APPLICAND If,meartnaking this Cenificmeof Exemption,you should - 310 — INTERIOR LATH
bac are suhjmt to the Worker's Com cammion previsions of oho tabor Code,you tun
O G
forthwith comply with such provisions or this permit shall he deemed revoked 31.1. — SCRATCH COAT
F " 313 — ROOF NAIL
CONSereisa ION!LENDING NG AGENCY
a 7 1heathy affirm that Pareiss construction lending agency for the perlbrmance — f
LT7 Lathe,',KnorwhichshispermitisissucdlSax.3097.Civ,CJ SQ1 FINAL ELECTRICAL ENERGY .-
ram'sAdnress 502 — FINAL PLUMBING ENERGY
C1certify that Ihave mad this appbeadnnanlmanthe al,weim'nrmanrn11 503 — FINAL MECHANLCAL: ENERGY
w F correct.1 goon tr comply with all city and crtmty mdativess and store taws slating 804 — FINAL BU I I_D T NG ENERGY 4 U cobuilding rrect.Iu,nmwcsiomandnerebyauthorl a representatives mciativesnfndstate molder upon
the aboveemmi.ned p.,my bour,penum purposes. S05 — FINAL ELECTRICAL
�t 0. (We)agreau,sme,indemnify and me,harmlea the City of CL,nino ego t
fr fn limhili ties,judgments,costs and expenses which may in any way acerae vgainaI xu 506 -- GAS TEST
U by in antcrqummc of trio gran g of thix.,miss
PPLICA TEST,. N I ALLNUN PO Issued by: .99j`7 —+ F T'Ikl(]I RLIJQIFLL NG Date
OR si W
dA otic se ) Re-roofs —-FINAL MECHANICAL
ZARDOUSMATERIALSISCLOSUR p S09 — FINAL GRADE
the applicant or future building occupant score or handle hoz: n hrlte'a Type of Roof
as debded the CoNnit,Municipal Code,Chapter 9.12.and the Hen,lth mdsmty - 51,0 — FINAL PLANNI*NQ ..
Code.Sectio 5532(.)7
O Yen No All roofs Shall t5ldspeete0pllill Ito anydrsnfPls rpk k0f§eing installed.
Will the applinam.,Famre building occupant use equipment or devices which If a roof is installed without first obtaining an inspection, I-agree to remove
emit hazanhms air cnmmninamts as deli tied by the Bay Area Air ouality Mmugement
Dl,tdarr all new materials for inspection. • nderstands an ill comply with
0Yea \No all non-point source lati
Wd.,
the hazardous materials requirements under Chapter 695 of the
&Safety Code.Sections 25505,25533 and 25534.1 understand that 1
s urn cement,have a mount,that a is my roponsibility rt notiy thequiren mu rlor m Ixsnnnee of a( ro .f Sig urs of Applicant Dat
engem D All roof coverings[o be Class "B"or ,Iter
OFFICE
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