00060075 CITY OF CUPE RTINO
IS1111.I11N(' 1 tsto ' IT CONTRACTOR INFORMATION:
FOUR SEAROING Rnnli 00060075
BUILDING ADDRESS: 1'ERMI'INO,
F.CEEMON VEST AND Ill I TRI-12 F45 MORNING RT 06/13.12000
OWNER'S NAME: APPLICATION SUB DATE
41 'HONE.: SANITARY NO, CONTROL NO
O ZARCHITECLA NGINF.ER: BUILDING PERMff INFO
�u O O BLDG ELECT PLUMB ME CII
�?z LIC.ENSEDCONIRACTOR'SDECLARATION RE—ROOF Job Description
Z_n] III hynlfr"t'hal Ism licensed under pnwisionsnfehne"9(ammrmnemg
with Secdon7g0(B'al'UlviMon3oflhe lBoinsco—od Pndesrinm Cade.and nI,tonne
a I.al lull force nod Oliver
a OU Lisnne L'Cus Lic.#
Is. Ilam Cmmrimmr
5++ AItCI 111'PC'I"S DECLARATION
i 1 unde sand Any plans dbull be ural to public records
E �
w d O O LisnecA 1'nrin,inn:J
OeaI a,BUILDER DECLARATION'
"Z� 1 hereby affirm that 1 1. eseard rain me l...Co Licca"Law tar the '
(-Z n followinguires a (Scaler 7031 s,tlusire,land or.denons Code Any cit,or envoy
x p which requires o permit m ennnaa.o'er.improve,Demolish,nr repair any nmcmre
ii a prior to its issuance.alnn nan
requires the applicant for such pent)file a signed statementmat he;s lasso"J punuam m,he pmrisiens of the Commcmh License law(CTzpmr9 Sq. Ft. Floor Area a ua ton
(commencing with Section 70 X1)of Division 3 of the Business end Professions Crxle3
nr Bad he is excmFn thmef sin and,he bad,for the alleged emarpaion.Any violation A MIA
of Section 7031.5 by any applicant for a permit subjects the applicant In a civil penally
.fit.,mem man Eve hundred dollars(S500). AP e Occupancy Type
01,as owner of the property,o,ray employees is It wages as their sole compensation.
will do the work,and the structure is an,intended or offered lin sale(Sec.TIHJ, ,� —
Business and I'ndcoinnn Code 'fhc Cnmrxmr's License Law does not apply m an ljI[�ryf`I Spectlons
"net of property Who builds or improve,thereon,and who doer such work himself 307 — INSl.11kl
m,hrough his non employees.provided that such impavemeor,am not intended or Ea 1 — ROOF TEAR OFF
offemd lin tole.If however,the hold nr impavcmem is sold within one year of
Imnnma. ,me—aer-mrdderwlnhave mamlrdenarPradn„ ho,hedidnot mdlaor 602 — ROOF PLYWOOD NAIL
prov or alosoc of sale.).
01,at ownelaf 111,l,raperly,an e.emtid contracting wiat seemed eanneet la 603 — ROOF BATTENS
,l d "role”s 7ua lla f..- CII In L 604 — ROOF IN— ' GRESS '
Ls nl Allyl fp p , 'I h IJ: I' II t), t
nd wlnaw does
web pntyelaCF of a nnnauI...bur(O icenoidiorI pursuant nl m the
Canlrnclor't License Law.
Cl I sic cono,l under See .It�l'C lits this rcmon -
Owner I 6
WORKER'S COMPENSATION DECLARATION
I hereby affirm under penalty of perjury one of the following declarations: ` O�
1 hove and will mainotin a CcniGcmc of Consent to self-insure for Wnrkei s
401, provided us provided for by Section 3700 of the Labor Code. for the
pcm
rforar tt o,r the work for which,his pemlil is iaucd.
I have and will cul ado Workers Connpenwtion Insurance,as myuired by Section
3700 of,he Lahm Ctul,for the performance of the work for which this permit is
issued.My Worker's Cn/m/pemalion Insurance carrier and Policy number are:
Carrie,: Zu C.AA Policy N.,:'TCS 60er
o 0300
CHRI'IFICAI'[ON OP EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE
Ibixscdloa need n I he cnmplc,Id if he pen,ll is lin one hundred dolor.
ISI out or let")
1 vend,,hal In,he Ise lornnewe of,he work fns whilh'his Penni'Is isxucd,I
o,aH not cl"'loy any perxnn n any m ut sur su b m t ic the W..k,,,'
rannpelnwn,lo,layk nl;/Jmn'o�tyKUalcl `6r �" =eco
Apphcxnn, [�/��/J. �e
WINCE'r(1 AI'I'LIC 'I':IL aIler umkln,this Cenilieale of Exemption,you should
become subject to the Worker's Conpenwaon provisions of the Labor Code,you nm,t
Q 0 fnnhwim.nmPly with such provisions or this permit shall be deemed revoked,
F - C.ONSTRuc ioN LENDING AGENCY
I hereby affina that them is a cn"stmetion lending agency lar the perhati anw
of me send for which Ibis psnni,is issued(Scc.3W7.Civ.CJ
L Q L.cadr,Nana
Z LcnJefs Address
U 0I mnify,Ism I have read this oppli<minn and s,ae Ihat the obese infimnminn is
correct.L agree to comply with all city and county ordinances and state laws mining
(� mbuitcingcons,rvc,inn.and hereby.ulhoris repre"ntarives ofth;s city loenter upon
'he ah v,,reationed progeny ft)inspeclion Parise"..
F LS (W'c)a,rtc e,w,indemnify and keep hannl 'he Chyef C.,cra against
W habilirvle juJ,neal,coal,sort espowcs which may in any way:meme.,.last Laid
(� z
City;ncon"yu ND RIT PIS
SiA AND
pe CO
APPin canw UNce al he call of WILL LY WITH ALL NON POINT Issued by: Date
SOURCE l:fl'IONS' -1?-00
signal..afnppba,mfcamma,,, Dam Re-roofs
I IAZARDOUS MATERIALS DISCLOSURE r
Will dtc:g,pbewnt at nalem budding neeupon store or h:mdle hanardeae Iataedlll 'type of Roof
,rte dcdnIA by the Cupcninu Municipal Cole.Ch'mmr 9.12,ural the Ileul'h unJ SIJ'c,Y
Coda St....25532(r)?
uvea —ram' All roofs shall be inspected prior to any roofing material being installed.
Will lhes'ekador more haild;ng ocenpnnl use cyuipmual or deviser"mel, 11•a roof is installed without first obtaining an inspection, I agree to remove
ental hn'rardaut sir conolninm"s as defined by the Bay Arca AU(sunhy Mmrt,cntem
l all new materials for inspection. Applicant understands and will comply with
all non-poi t source regulations.
1 have read the lelc,Cod e..s nmlon,2 rc 5.25533 a under 4.1 un 6.95 of the
that
/ /1
if the wilding dM1K,,,ru G.le.Section?5505.,it
rnJ853J.lil,to and,the (//.r•- 6 .�
;(the building dyer urn nrrtemly have.mnanL,MI iI is my msp,msihili,y,v notify the
«nupam of Ila my,yrconcrat wyyh muss M ma prior to issuance of a Cer ificam of
cv,"y/L,C/f// Signa re of Applicant Date
G��3 c�
owner'tool .cda,ctn Dale All roof coverings to be Class "B" or better
OFFICE