03010004 c Try
c mvls�orvND CONTRACT R INFORMATION
PERMIT ter, -amu R-I N ,�..,��,...... .
OOILUING AI3URFS5: PERMIT NO.
20044 PACIFICA DR 03010004
'ER'S NAME: APPLICATION SUB DATE
STEINWEDEL JEFFREY A AND ADRIA 01/02/2003
I'1ION17: SANITARY NO. CONTROL NO.
ARCHITEC(ENGINEER: BUILDING PERMIT IN
BLDG ELECT PLUMB MICH
0 0 0 0
�00❑ LICENSED CONTRACTOR'S DECLARATION
ced b I hereby affirm Thal 1 am licensed under previsions of Chapter 9(commencing Job Description
iwith Section7(a)(Eof Division Sof de Busineamid Professions G,Je,und my license is
inminineanderrect. REMODEL KITCHEN W/BAY WINDO
Zp;Z License Glass C...a `a'PINAL.ED
oy-o Dale cnnra ter
F--'y ARCI IITECT'S DECLARATION
ow� 1 undersand my plans shall be used as public records
XLLOD Licensed Professional
DEC 1 3 2003
OWNER-BUILD17R DECLARATION
s c i I hereby affirm that 1 L eosin from me Contractor's Code:
e:Any c law co me BUILDING
m¢p0 following iciromerchy fromSect at I LS,exempt
m line Conirac or's L cense L w county
e' $K which requires a permit m aaaruct,alter,improve,demolish,nr repair any structure
prior to its issuance.also nataims the applicant for such Permian file a signed statement
that he is licensed pursu tato the provisionsofthe Contractor's License Law(Chapler9 Sq. Ft. Floor Area $50VOC ation
(commencing with Section 7kNE of Division 3 of the Business and Professions Code)Or
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Section 7031.5 by any applicant for a permit subjects the applicant to a civil penalty of Occupancy Type
mon more than five hundred dollars(S501).
❑ I.as owner of the property,or my employees with wages m their sole compensation,
will do the work,and the structure is not intended or named far rale(Sce.7044.Business ±8± Febilf
and Prefessions Code:The Commutes License Law dors mol apply tat as owner of102 - PIERS equired Inspections
property who builds or improves demlfon,and whodoes such work himuor through his
Own employees,provided that such improvements art not intended oroRered mrsade.If. 103 — UFER
however,me building or improvement is sold within one year of completion,the owner- lO4 — REBAR
builder will have de burden of proving dal be did no,Wild Or imprwe for puryoe of
.In 105 - ANCHOR BOLTS
1,as owner or me property,am exclusively contracting with licensed contractors to 10 6 - SEWER & WATER
ores ruct the project(Sec.7 W,Business and Professions Code:)The Contractor's Li.
cense law does next apply to an)wan,of prapeny who Wilda or improvex the an..and. 202 - UNDERFLOOR PLUMBING
Lwho CeneeLewufnm such projects withanmvacmr(x)Iicensedpunuenuo the Contractor's 203 - UNDERFLOOR MECHANICAL
❑IsmeaWp\nderSee. _B/&PCfor this remnn 204 - UNDERFLOOR FRAME
205 - UNDERFLOOR INSULATION
WORKER'S COMPENSATIONDECLARATION 301 - ROUGH PLUMBING
1 hereby aRtm under penalty of perjury one of the following declarations:
I have and will maintain a Ce ilicme of Consent self-insure 302 - TUB & OR SHOWER
❑ rcrnrwnrker'acnmpm 303 - ROUGH MECHANICAL
.cation,as presided for by Seninn 3]1X1 Of the Labor Codc,for the perfnmmancc of the
work for which this perran is issued, 304 - ROUGH ELECTRICAL
❑ I have and will maintain Worker's Compensation Insurance,m required by Section 305
- FRAME
0 X1 of the Labor Cade.for de performance of the work for which this permit is issued.
My Worker's Compensation Insurance carrier and Policy number are: 306 — HOLDOWNS
Carrier: Policy No.: 307 - INSULATION
CERTIFICATE OF EXEMPTION FROM WORKERS'
COMPENSATION INSURANCE 308 - SHEETROCK
(This section need not be completed if the remain is tone hundred dollars($](a)) 309 - EXTERIOR LATH
""em) 310 - INTERIOR LATH
I eertar tM1ul n n Pen me k for which this Permit is issued,1 sh ll not 311 - SCRATCH COAT
employany pc m ny exon rex as�n become suhjenmthe Workers'Compensation
LAewinl Califf a. �- f S 313 - ROOF NAIL
NOrPrLICANI':It.after making this Cenilicaa of Exemption,You sound 501 - FINAL ELECTRICAL ENERGY
1eomc hjeclmtheWorker's Compcnmtionprovismnsofine LZWrChun.youmas, 502 - FINAL PLUMBING ENERGY
Z forthwith comply with such provisions or this permit shallM deemed revoked.
z0 503 - FINAL MECHANICAL ENERGY
1 hereby CONSTRUCTION is aconstruction lend .)agency[or the rlormencenf 504 - FINAL BUILDING ENERGY
the work for which this permit is issued(See.3(Nl7,Co,iv.C.) 505 - FINAL ELECTRICAL
Lk1 Lender's Name
�z Lender's Address 506 - GAS TEST
U 0 1 cenify that l have read this application and slate that the above information is 507 - FINAL PLUMBING
CLF Correct.1 agree to comply with all city and county ordinances and nate laws relating to
0 huildingeonsuuction,and herebymillouLerepresentatives OfOISCinymenseruptathe 5 FINAL MECHANICAL
IU aove-mentionedpmpcny for inspection purposes. O9 FINWE(We)agrae to save,indemnify and keep harmless de City of Cupenino against
V) liabilities,judgments.costs and expenses which may in any way acmeagainst said City 5j NO Z in consuence of the granting of this Permit.APPLICANT UNDEeqRSTANDS AND WILL COMPLY WITH ALI.NON-POINT Issued by51 ORKS Date
ZRC�REGULATIONS.
� - JJ?,/03 Re-roofs
JiNP app as VCommcrR Date
HAZARDOUS MATERIALS DISCLO F. Type Of ROOF
Will the applicant or future building oecupent store or handle harardous material
defined by the Cortone Municipal Code,Chapter 9.12,and the Health and Safety
le,Dyes 25532(4)? _ANo All roofs shall be inspected prior to any roofing material being installed.
t Will the applicant or future building occupant use equipment or devices which
If a roof is installed without first obtaining an inspection, I agree to remove
emit hatodous air contaminants m defined by the Bay Area Air Quality Management all new materials for Inspection.
District?
❑Yes )dNo
1 hr.read me W cad us materials icquircmenu under Clmpmr 6.95of in.COO,
ria I Iwlth&Safety Calc,Settlors 25505,25533 and 25534.1 undersand that If the building
does not currently have a tenant,that it is my responsibility to notify the Overtrain of the
rcyvimmcn ' nmunbemel d nissrtanecafa4nificamnfOccupancy. Signature of Applicant Date
Owner vcJagcnt „e All roof coverings to be Class "B" or better