01110077 CITY
BUILDING DONPERTPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10271 MIRA VISTA AV CALIFORNIA POWER AND LICHT 01110077
OWNER'S NAME: APPLICATION SUB DATE
SETT WILLIAM H AND TONI E 8887 LILLY AVE 11/16/2001
j PHONE: SANITARY NO. CONTROL NO.
4088470520
❑O C ARCHITEC ENGINEER: BUILDING PERMIT INFO
1°U 2 BLDG ELECT PLUMB MECH
l_I LJ L__J 1__I
LICENSED CONTRACTOR'S DECLARATION
mad
5'? Job Description
z=„ 1 b,rtby uftirm thin Iran afthe E icer Drovnions of Chapter 9 and
license wf-u with Section 7000)ofDivision3ortheBusinessandPro@ssiomCode.andmylicensc SERVICE CHANGE TO 100 AMPS .
y f= o ro ntn rid«e a r�erre�
License CI s OT Lie,p O
c 3 a.V Date _} o' (gam Co
ARCHIT 'S UGCLA A'
:-0,u I utWmmnd my plan,shall be used as puhli.rannlz
:tt3i—
ap O Lwemed Profewioml
OWNHR-BUILDER DECLARATION
uai 1 hereby of.that 1 in exempt from the Canranor's License Low for the
t?a following neawo.array t 9o3L5.Busitters and are.demolish,
e o li Code Any city or county $2000
o which requires n permit requires
e ronswa,alter,improve.demo it t or repair any structure
�3ov pdonot also q eprapplicantf chrami'totilaae Law(Chapter
- -- — —
thmle I'<n dl'suen thy' Ionx fth Contractor's Lcen.a law lChep¢r4 $ Valuation
Icon M g,.th5en' "!(MMI) fD isio 3 fth B- ass and Professions Codel g .1l.v ,'+t3 S410,2!��jr^-'��'i
or that he is exempt th orfmm and the basis for the allegW exemption.Any violation
M Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty'
ofno,..than five hundred dodaw(S5on. 304,PNlk5egH ELECTRICAL ' Occupancy Type
°1,as owner of the rmpeny,or my empluyce,with wages as their sol,c°m ic.'o inn,
rill do the work,and the mmemre is nm intended or'offered for sale(Sec;70t .
Business and Professions Code:The Contractor%License law does not appy to an 505 — FINAL EE W gWjl(raqgtions- '.
owner of property Who builds or improves thereon,and who does such work himself
m through his own employees.provided that such improvements are not intended or
.offered forsale.IC however,the buildingbr improvement is sold within one I'-_. ._. .. ... ...._._. .. . _ ... _ .. ...__. ... ..
p.mfinen year o
completion.the purpose
of sal.).will have the burden of priding that he did not buil)or
Improv[for purpnx of salt.).
. . ei . .. - .
O L as owner M the nmpe.71 am excursively contacting with licensedcommentsComemrs m
License the does
n (See.Ito a ownBusier of and property
w ons Cede,me contactor. DEC 0 7 2001
License co dos of apply men owner of property who builds se improves thereon.
and who ronwens to,such projects with a rontrnctoR)licensed Wrsuam to the. ... . .. .._. .._ _.. . .. .. .. _ _
Contraaoe License Law.
L. ❑1 arm exempt unJer Sec. .B&P C for this reason `
Owner Date BUILDING'
WORKER'S COMPENSATION DECLARATION
1 hereby affirm under penalty of perjury one of the following declarations:
f1 ❑ 1 have and will maintain a Certificate bf Consent to selGmsu a for Worker's
t compensation as provided for by Section 37W of the Labor code, for the
performance of the walk for which inspection is issued.
-' °1 have and will maintain Workers Cnmper,ovm Insurance,as rocnied by Section
37W of the Labor Code.for the performance of the work for which this permit is
issued.My Worker's Compensation Insurance carrier sad Policy number are:
Cunec fill--• "'- ' ' t s Policy No.:• P k t, i ,�u'...i'l(•{ ,Jr .) .-ty '. a .. :
1 CERTIFICATION OF EXEMPTION FROM WORKERS', l
s -
..COMPENSATION INSURANCE
(This sect on need hot be completed if the permit is for one hundred dollars " 1
ISI Off to less.)
I certify that in the performance of the work for which this Permit is issued,I
,hall not employ asy,aatrpe become th Workers -
Compcnm snL m D t
NOTICE O
O bAeP LIC fking this Cecilema o you should
QmhC pe sat provisions of the Labor Code,you must
forthwith comply with such
p mob,Permit shell be de m d revoked.
F i ' '. CONSTRUCTION LENDING AGENCY'
E
0 1 hereby alfrm that there is a conswetion lending agency for the padminance
W.Q
of the work for which this P,nint a issued ISec.3097,Civ.C.)
Lender's Name .. .. .` a
�"' Lenders Address
l.7I certify that l have need this application and state tam the above information is '
kw [..: <iibem.1 agree to comply with all ciiy.und county,ordinances and state laws relining
O.fJ to Wilding conswetion.and hereby suthorim representatives of this city to enter upon
} (g] the above-mentioned property for inspection pump was.,
rp. (Way igree to save,indemnify and kap harmless the City of Cupcnino against
rn liabilities,judgments,costs and expenses which may in any way accrue against said
.f, Z City in consequence of the granting of this permit' "` r
APPLIC ftSTANUSAn .L CONI 'W THALL'NON-POINT Issued b Date
SO' REGULATION ,O y'
oder re.fA nmtor . . ate " -roofs /
- gra p HAZARDOUS MA F.RIAL$DISCLOSURE Re
I the apPl dam for..building +'cupam store or handl.hazardous material Type of Roof.defined by the Cupen n M niclpal Code Chapter 9.12.and the Health and Safety s
Carl Section 255321a)? .. ...,., a ,--
0
- . '• (
°Yes " '" ,.ono ', ,r,.:'s _ -All roofs shall,be,inspected.prior to.any roofing material being installed.
Will the up pi icent or future budding occupam use equipment or deviceswhich If a roof is installed'without first obtaining an inspection;'I'agree-to remove
emit hazardous air contaminants as defined by the Bay Area Air Quality Management
District+ all new materials for inspection. Applicant understands and will comply with
\ °Ysa - - ONO- all non-point source regulations.
\. 1 have read the hazardous materials requirements under Chapter 6.95'of the
California Heihh&Se@ty Code,S<ctinns 25505,2553a and 25534.1 understand that
if the building down only have a poram.than it is my responsibility to notify the
occupant n tenements which a be a to issuamce of a Citation.of
° " ^. Signature of Applicant Date
caner oriz agent Dale; All roof coverings to be Class "B" or better
�
OFFICE -- ..