01080051 OF
ctBul DING DIIVISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
10192 PARLETT PL 01080051
OWNER'S NAME: APPLICATION SUB DATE
SOFYAN NUGROHO 08/09/2001
PHONE: SANITARY NO. CONTROL NO.
0 O O ARCHITEC[ENGINEER: BUI MG PERMIT INFO
BLDG ELEeF PLUMB MECH
LICENSED CONTRACTOR'S DECLARATION
C 5 N= Job Description
O Z_ 1 hereby affirm that 1 nm ofthe B muter provisions of Gbapmr 9(commencing
p„�w is in se[hore am eof ect. n3mnne eaameaa led Profeaamna Code.and my hon.= CHANGE EXISTING
CC LIGHTING.
aYfJ isin (lase am cRas. �I�Vf'1�GD
no w a License Claes Lic.p
y a O Dam Contractor
Fa0 t; ,MCHUEL S DECLARATION
an
g I understand my plans shall be used as public records 2 3 2002
X s p O Licensed Professional ,100
>X u z OWNER-BUILDER DECLARATION
in 1 hereby from that 1 an,exempt faro the Cmummors License Law for the
F z following reason.(Section 7031.5.Business and Protestors Code:Any city or county,
eO which requites a permit to construct.alter,imptnve.demolish,or repair any structure a+'s�i C 1.. 13�, $100000
6;�...priorm its issuance.also requires the applteam for such permiuo Tile a signed statement ---- - - -
QatheislicensedpursudrntothepsvvisiunsoftheConvadorsLittnsetaw(Chapmr9 .re�y j�sppprQ[Qa _ Valuation
(commencing with Section]t100)or Division 3 of the Business and Professions Cade) ;, :.. 1 :3 P92 �V�t5.: V U. }�'.-x 1 I.`t R; '
of that he is exempt thinifForn and the basis for the alleged aacmption.Any violation
of Section 7031.5 by any applicant for a permit subject the applicant to a civil Penalty p�f�y
lof not mare talar five nattered dollars($500) 304APN 1Wti €1 ELECTRI AL Occupancy Type
UN,as owner of the property,m my employees with wages as their sole compensation, 504
os6ill'do the work,and the immune,is not intended or offered for sale'(Sce.700.1,
Buintess and professions Cade:The Contractor's License Law docs not apply to an 505 - FINAL EJtv1bRct bAmctions '
owner r of property Who builds or improves thereon,and who docs such work himself
or through his own employees,provided that such simon,Nwi are not intended or
olread for sale.q However.fine haulm t a.loll wiNiaaM-eu sir
completion,the ownervbuilder will have tdic harden of proving that he did not build or vl \ s
improve for parties of vie)
A I/
I'�1 .mane of the propeoY m exclusively contracting with licenser!contractors to
.. .wt'hProject S 70,14 Business andProfession,Cod '.1 The Carl .tar's
License Law does not apply to an owner of Property who WiLds or improver themon.
_und.who.contracts for.such pmjmB wird a contractions)fiverned pursuant to the.
Contractors LcLa _ 2 <
r ❑I m c cmp}`dar,S _. B&PCT thisi.' 5 S
Owns a '
WO K C MPENteSA'110N DECLARATION O
1 hereby M.unde,,,nntry of cerj.,y eine or the following declarations:
❑ I have and will maintain`a'Cinificam of Consent to self-inmre for Worker's
Compensation, as provided for by Section 37M of she Labor Cale, for the
Performance of the work for which this permit is issued,
0 have and will maintain Worker's Compensation Inaumnce,ai requires]by Station
'37p cif he Labor Code,for the perforbtunce of the work For which this permit is
=i 1 issued My Worker's Comnii!a ion Insurance envier and Policy mother arc:
.. nt1.1., ys✓',f ......... ......� ..... ... . _ _-.._. titin' Ati r .. , _. .. ._..�....,�.......... 'sit,i. .....�....�..-
Carzicr: Policy Na: s s5'l'i( .,t1!' �'+,�' s
'CERTIFICATION OF EXEMPTION FROM WORKERS','
.. .: COMPENSATION INSURANCE' _ __.___,___ ._ _._.,,_ --,_ .. _
(This iauin;raced not hdnitnplm,nI If the permit is for one hundred dollars ___ '•f.a v �`1 -a. :tl C' P't,r,” by i
131001 or lea.) .
°f lenity that in the perforrainceorde work for witch the permt is mued,I - � - `• J t a•lvs<, ( , - -
,hall noso
t employ any person in anymanner so as to become subject or the Workers -
Compensation Lowx of California.Dae-
..A 1 am _-_... _ ._ _. ._. _ _. _._ ____. .. _-..__. - __ .... - _ _
"NOTICE 90 APPLICANT If after making this C rrforam a f Exemption you should '
.become subject to the workers Comisa
perion provisions of the Labor Code,you must
0 form,ith comply with such provisions.,,his peons,shall he deemed revoked.
�, _.. _._.... ._.__.. ., _ _. ......,_ _ -
.[:. 'CONSTRUCTION LENDING AGENCY"' 1
,a 7 I hereby afOrm that then is a construction lending agency for performance
sof do k f inch N p it' i...ad(Ses 3097Co.C.1
-5:z 'Lenders Adaiexs,.
V 1 certify that I have read this application and.vas¢that the above informadmn is
gT+' 'forret.I agree Ronald)',with all city and county ordinances and natela is mlaing
to Wilding trw tin andh itbi authorize repre,i%nitivesfth'.cityt ter upon
the Iname mentioned property to, spat on p m,N. '
(Ne)Wilma to sii.,indemnify and keep h ands the City of Copan o agaas,
(/I liare,1 ,,mmol. t an aWhil.
n any Y cc against sat J
U Ciy y soft 6 f _.APPI ANT ' ANDSYWITHALLNONPOI 'TI$$uedb Date
SOI' CE :GULATION' y'lure ofAppli[anVcnntmaor •.' Re-roofs
HAZARDOU ,IAIERIALS DISCLOSURE -'�'
ol11 thill,licam v,fture building occupant swrc tur harriall.h ardoas material Type Of ROOF. .. _. . _ .._.. -. , .. _,.y.,,...._.. - _. ....
e defined by the Cur,,tion Municipal Code Chapter 9.13,and the Health and Safety
col'Oye xis z"15""soya, All,roofs shall_be.inspected prior.to any.roofing.material.being installed. .. ..__..
Wift dre applicanto f num Wilding occupant use equipment or devices which If a roof is insfalled'without first obtaining an inspection,'I agree t6 remove
mon he,ardlmoi air c.maninarts as defined by the Bay Aura Ail Quality Management
District! - all new materials for inspection..Applicant understands and will comply.with
El Yes r ,E)No all non-point source regulations.
.. tris
1 have read the hazardous materials requirements under Chapter 6.95 of the
California Health&Safety Cale.Sections 25505.8533 and 15534.1 understand that
ZWWauss not ancntly harcatenam.th is my mspornibiity fib ndtifY Ne she req em wise unifCSignature of Applicant Date neaagent' Date. All roof coverings to be Class "B"or better
OFFICE