01110082 TINO
CITY
I BUILD NG DIVSI
iSiONPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO
10340 MORETTI DR. 01110082
OWNER'S NAME: APPLICATION SUB DATE
SUSAN TRELEAVEN 11/19/2001
I PHONE: SANITARY NO. CONTROL NO.
C111FO ARCHITECT/ENGINEER: BUILDIN RMIT INFO
w C BLDG LECI' PLUMB MECH
<E
8 w i LICENSED CONTRACTOR'S DECLARATION Job Description
Z•�+ 1 hcmby orrm teat I am liccmed mica provision,of Chillier 9lcommencing P
„_til, .ehnsenian]aalarDi�i.ian3artneBm.inesandPmttssinn:ende.anemyueenK TEMP POWER.
C Y Y J in full face and effect.
i z x< Liame Cla,s Lo.a
( n V Data Conlmclor
a ARCHITECT'S DECLARATION
V1 I understood my pram shall be used as public records
,ac O Liaensxd I'rnl'mainwl
Oxt I am
m the Contractor's
I rosea athdm ons 1 1 exempt from Inc Cessions a License Ina co the
< following rcamn.(Section]031.5 Business and Profession Code:Any city or county
$100
Y F o is re4uiro a permit to construct,alter,improve,demolish,or repair any structure
i 3 2 poor rotapplicant - .
Mah'slimnwdpmuanti6ap iI Pr _....___._.... al
also req tlwsuc perm uo leaugiwl nil¢mem
sof the he Business
s roadP lnwlns e 9 Valuation
(commencingath Sanol'@111fB tDl'askfrr t the Buedexerrip Pn.Any Vs Code) i�1.. ] vs'�,�f�.�kP,9r'.2ffP"i
or that he ti 3L5 b th6rcfmm and the From,
for the alleges exemptmn.Any vro natty
-of Section]8313 by anYapplicant fur v permit subjects the applicant to a cidl Penalty N
of nm tame than five hundred doBaa a5W) 10 3SPN It"ff . . Occupancy Type
❑1,as a..'ner of the progeny,ormy employees with wages as their sole compensation,
will do the sort and'the'stmaure is not intended or offered for sale(Sec.'70ol
•Business and Professions Care:The Contractor License Law does not apply to an Required Inspections '
nam r p perry wno n la. n Dues n erean and wood nwork himself
or through his mpl r ..pc ded that such .......c t: t intended so
offered f 1' if h he building or innonwinam is slid widdWorce y f
completion,the owner-build 'll have the burden f proving that he did no Wild or
fth p pcnY d . ely urictn6 a t tut
with licensed
construct theproject(S a 7044 Business d Professions Cartel The Contractor's
License I d of apply owner of properly who buil..,or ImImprove.thereon
and ho contmns for such groan,win a contractors)Bcenced.puisuant.so.the.
COoo01 mnor•s License Lew. _
Oleme anM under Scc. ' �• B&PCfar this reenon I � f!'..'...i'•,' " i'
11
W�ENSATION DECLARATION
I hereby affirm under Penalty of perjury one lithe following declarations:
❑ 1 have and will maintain a Ccnincam of Consent to self-insom for Warker's
5 Compensation, os.provided for by Section 37W of the Lahr Code, for the
Performance of the work for which this prom,is issued.
❑1 have and will maintain Worker's Compensation Insurance,as icquired by Section
37W of the Labor Code,for the performance of the work for which this permll is
i.ssbed.My workers Compensation Insurance carrier and Policy number me:
.. _ - ..._ ...... ...
Cam i 1It f ! 1 (.'`el Policy No. f l". " .1�f\"J f'\1 .
it i CERTIFICATION OF EXEMPTION FROM WORKERS'y' - l
... .__ .. .:_- COMPENSATIONINSURANCE
'I (This sorrioa need not be completed if the permit is for one hundred dollars \ "t .' d - r'„I'y•. !;h”
ISIW)ar lnsJ „
I eemplyha in*the
son in
e of manner
as t for becomenthis jectto re issuad,l .I;. ,; '�, ,.^grit ..•.,.�. `•
shall tiro employ any Person in any manner so as m become subjcn m the Workerti
compensation Laws of CaliforniaC .DateAppli `
NOT(tet h
NOTICETOAPPLeWorkraCoafter making this Ccninmc ofofEumptiode,you
you
-
bchnoeSunocomtheWorker'svikim,or
provisionsaerr the Carred Coda you must
Q 0 ro---- comply with such provisions or this permit shall be deemed revoked.
Ln I,r ' "CONSTRUCTION LENDING AGENCY
ra " , "
1 hereby affirm that there is a ronsiruaiun lending agency for the verfunnance,
Wi of the work for which this permit is issued(See.309],Civ.CJ
aa'� Lender's Name.. _ ... .:.......... .__ _. _. .. . .._ . . _ ..
Casa Leader's Address
Es cbrtecdII agree thcomply
omplye artiame all this aprtplaincdaticounty
d ordinances and ouvsee inlafowrsmraetliaoninig
C. build ag convocation,and hereby artheorric reprasenottivaS s
of this city t enter upon
C�.•7s.06. the ate(We)agreeiod,perropcnyd fte�npand
keep
hipa
ro.m
less the Cry ofC pen 'againOst
Z) liabilities.judgments.c I d expenseswhich may any ysug 1.et said
Citynconsequence af the granting fthis p rm s
r _C//7IL CUNDERSTANDSWI COMPLY WITALL NON Po1 T Issued by: DateOEREGULATIONS
. Sigmnure of Applicant Conlrumhr - Date Re
-IOOfS
SHAZARDOUSMATERIALS DISCLQSURE
;Ali]ae pplicanta occo
fumiebuldingWt - handl nazarribr.iaa, 'al Type of Roof
as defined by theCupenm Municipal Cod Chapter 9.12.and theHealth and Safety
Yp
Codc Section 255321.)
❑Y. . ❑rye': ' ..—All roofs.shall be inspected prior to any roofing.material being installed.
'Will the applicant or future building occupant use equipment or devices which If a roof is initalledwithout first obtaining an inspection; Iagrte'tc remove
emit hazardous air cnnmminan¢as defined by the Bay Area Air Quality Management
Dion.? ' all new materials for inspection.,Applicant.understands and will comply with
❑Yg oNa.•; ' all non-point source regulations.
^I hdUa lead'me htiardous materials requirements under Chapter 6.95V the
California Hc]IIh&Safety Code.Setdoru 25505.25533 and 25530.1-undemond that
if thebuil of
he requirements
which
thwitiamy re..are of tovodite of -- - - -
c'upant of the iwhich must be mm prionm issmntt of a Cenincam of
afp y
Signature o (cant Date
O,oc,toa m tred og onter Date ' All roof coverings tobe Class "B"or,better
;.e.. ...:._ . . .. '. .. OFFICE