01100138 CIBUILD NG DIVISIONSINOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10340 MORETTI DR. SUSAN TRELEAVEN 01100138
OWNER'S NAME: APPLICATION SUB DATE
SUSAN TRELEAVEN 10/25/2001
PHONE: SANITARY NO. CONTROL NO.
n-O ARCHITECT/ENGINEER: BUILDING PERMIT INFO
u C BLDG ELECT PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
1 herebyRum that 1 am licensed under of Chapter 9lrnmmcmin Job Description
withseetion 700)°fDi.isi°n3nfine Baseness acrd rProfastions ewe.ane my Ocenu DEMO.
f m y_, is in full force and effect.
z oc 6 License Coss Lie.a
a DafeCourremr
s LL LL y ARCHITECT'S DECLARATION
] O_1 I understand my plans shall be used as public records
'eni i c,O Licensed Profesaionml
o OWNER-BUILDER DECLARATION
1 hereby.(Seen that 11. cscmnt from Nc Cession C s License Law for the
oc z a whichr following reason.ernot to 703 construct,
t,amass and improve,d Professions ewe:Any city or torture $8000
oc o which q x n m m n r, mprme demolish,or repair any structure
w�m
a — that he I'a ep h Into 0cp I sof the Commcwrs Lscn.n law([hepta 9 /_I — _
(commencing with Seet 21X10)otDvision3oftheBusnx,� ,soP,pfic'si...Cwe) 6.4 _`Tly( J,]e' 'p']� YrpJdlleLr�•�h{?t's ' Valuation
or teat io is exempt any
a um ani the haws fnr the alleged uemant to Any l Pennon
-of Sermon 1031.5 by arty applicant for a permit subjms the applicant to a civil penalty '
.ofnmmorethanfive hundred dollars($5f)0), NO 'APNq `b INSPECT ONS r'' Occupancy Type
01......
of the property,nr my employees with wages as their sob compensami°n,
will do the work,and the structure is not intended or offered for sale(Sec.7(p4,'
'Business and Professions Code.The Contractor's License Law does not apply to an Required Inspections"
owner of property Who builds or improves thereon,and who does such work himself
or through his own employees.provided m tom such improvementsissolare not intended or t
offered for vale.IL hrwcvcr,the Wilein6 or immm
pveem is sold within one Year of -
completion the owner-builder willowner—build have the burden of proving that he did not build or
prove for Purpose of vall 1 x
Pexclusively cotmnBith]canted tj (asownerofthe rnnaors�o
wet the project Sec.70,14,Bus uex. d Professions Cud )The Contractor's ` „ it"H
1:cense Lau dues no, Pm a ner e f P party ho builds p s mh
mud.whm um s for such p lett. with ttmractors)TceuJ porinvord to the
Contra<mrs License
Low
-,
❑l am en tInd"St " 'B&PCT this reason L' la SS4
P eJ
owe E.I-rA err--
ORKER 5 O 1PENSATION DECLARATION
I hereby affirm under Penalty of perjuryrine°f the following declarations:
0 I have and will nairmin a Certificate of Consent in self-insure for Worker's
Compensation,as provided for by Section 31110 of the Labor Code, for the
il performance fthe work forwhich this permit.issued.,
O 1 M1ave and will maintain Worker's Compensation'tax...ace,'as required by S«tion
v 3100 of the labor Code,ftii the performance of the-work for which this Permit,is
issdcd.My Workcfs Compensation I stones carrier and Policy number arePol : ��,,11
Com,.er? CL'RTIPICATION OF EXEMPTION FROM WORKERS '"!�' > +'� tlC•lF tu'hl f12 L1 t,,},et.b.l: -- - S"I' '.l,ph _—
-' - MPI:NSA'I'ION INSURANCE' I'"
v ILL('this uc,'on
rieod'nm be compleieA if mhe pvmim is for one hundred dollars "• - t - i:CU I J :: 1•j
(1a 00) less.)
_4 certifl,.that in toe parformanceofthe work for which this permit is onsucd,'I
shall not employ any person in any manner so as to become subject to the Workers'
Compensation Laws of California.Date
Applicant' ., . .
NOTICETOAPPLICANr If,after making this Ccnificate of Exemption,you AWI15
become subject to the Worker's Cnmpeatlon W
provisions of ire M1ur Code,you must
0 O m
forthwith'comply with such provisions or this Permit shall Ne deemed revoked.
z •'�""" •CONS7RUCTIONLENDING'AGENCY
1 hereby affirm that there is a construction lending agency for the performance
Wy of the work for which this permit is issued(Sic.3091.Civ.CJ
Nairn,
Lender's Na "' .,"
.: .. _. ..
6t Lender's Address
,i'certBy mm I tr ve read tMs.,liemmo trod state ton the above information is
W
to correct.I agree to comply with all city and county ordinances and state laws relating
O�U to Wilding conswction,and heaoy aumhmire reireuntatives of this city to enter upon
;v„ W the above-mentioned,Property for inspectioaPurposes.,, . ,
1Irr A. (we)agree to save,indemnify and keep harmless the City of Cupcnln'o against
0 liabilities,judgments,costs and expenses which may in any way accrue against said
U � City in consequence of the greming of this perm:[
APPLIC NT UNDERSTANDS'AND WILL COMPLY WITH ALL NON-POINT
user E,ULATIONs�— Issued by: Date �O — Z(,f'�
Signawre of APplicanUCmntrstbrDate' .'i Re-roofs
HAZARDOUS MATERIALS DISCLOSURE Type Of ROOF _ ..
Will the ppl cant future Wilding awwwrc pant there or handle harardoits matcnil
as all by me C pen M Pp I�Ch pt 9 12 and the Health and Safety _ s
Code5ro 155321a) I1 rer Ert '.��'It
-. ore: - ❑ n r - _ All roofs shall be.mspected prior to any roofing.material being installed.
n.
,Will h t arpl cv f t b Id ng y v t e qtr p < t or device,which If a roof is installed'without first obtaining an Inspection;'Iagree.tosremove
cent hazadosuI,rommirii ani,e.def ythe'ByAcs A Quality Mmogemcm
District? all new materials for inspection Applicant understands,and will comply with
°Y' the haurdDos
sad memrial; : .1 all non-poinI W, t source regulations;
;
e - regmrcmenis under Chapter 6 95 of the
California Health&Safety Cwc,Sections 25505.25533 and 25534.1 understand that
if the building does nom cunemly nave a menent.that it is my responsibility to rod y the
occupant of t -
enc he 4cquiumenti which must de toes prior to issuance of a Cenifican,of
Oceu
p y^ . �, - Signature of Applicant Date
nernraPmnurireeagent - Date All roof coverings to be Class"B" or better .
:`• .moi - - _ - OFFICE