01060003 CITY OF CUPFCONTRACTOR INFORMATION:
xml.omcmvISION tstory PERMIT
BUILDING ADDRESS: PERMITNo.
Ac ossa, /' o
�/j fJ DATE /�
UWN:R'S NAME: i. Ie—/ . /,C�6/l_,r, APPLICATION SUB DA
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PHONE: U - F/✓ SANITARY NO. CONTROL N
40
a z ARCHITEC'U iNGINEER: I3UILUING PI:RMI' WFO
O O [� '7 BLOC /ELECT PLUMBB h1ECH
a u�i -7 J 3 77
C(X CI I-1 I_7
S i LICENSED COM'RACrOR'S DECLARAi'ION Job Description
Cv ' I M1ereby aRnn that I nm IirenseJ under pmvisiotn of Chapter 9lcomtnencing
w wish Sermon]IXXq (Division of Me llnsinessanJ lknfessions Cole.tied yli n
�x�� i.inr,dlfame'' 3 T 5�7�
ULiccme Cla,x_ e _ Lie.«n
w 3 w Dole
ARCH ll thm used.,
public
.TION
I unJcmmnJ my plans sM1SII he used a.public mroNn
y}
zLicensed Prcdcvional
y o y Om I mal eUII_ULR DECLARATION
w=u 1 reaso affirm that I am exempt s an the Conium Coss:
Liana ty o for the
whicwingremmn.(Sectinn]j3L5,Businer.lanJve.deoli Gxle:Any tiny or county
O which its iirce a pcanh m cables
the
6 anima ivtnuvc,h per I,' or repair a should
any stmaurc
prierto innarouse,,also rsuant it)the povioturoncfor suchperIIInae1-ziw( hapInrm
j= wommehe shamadpSectio tamep fDovin,n 3 o Contractors Business
Lian,e Law(Chapar9 Sq. FL Floor Area Valuation
or that a is cwith Section]000)inaofhe basisJof the BusinessmJProfessionsltnon
or that he is exempt zany a li and the Nvm for the alleged,(Basion.any lineman,
of Section]IDLs by any handled
danl fir 0500). subjan inn uppllcmn m n civil fwwhy
norm tn,re teas B.n naanmd dnllam 6san. I IAPN Number Occupancy Type
❑1,as owner of the pmpeny.ur my employees with wages as their sale compensarnn.
will do the work,and dre structure is not uncalled nr offered for sale(Sat.]Mi.
:rine„:Ian Prnm,simt.Code:The Cmanctn,s License Law does not apply to an Required Inspections ..
—urrol property Who Hood,or impmvc,thereon..,at who dis, .,h wore cro,ell _
or through his own employees.pmvidod than Hach in.prn.comb s arc not intended or
oRered Earache.IL huwever,the building or impewenme,is sold within one yem of
completion.the rM1 rt
lmoc the burden f provingthat hdo,notior
'nP a Pd )
01.as ill the property. exd : 1 contracting d licensed I ehsto
!m t the p ) IISe.7d4R dr fc: LmM Th C trm
1ci L does nor apple to an owner of p pe,y
who b Id. pm':lto be h /
nam wt u au
ms I'awt sh pnfiaIM1
cs w v sit nmund,l uncA pu u S m J
C]I..e ',Liccne, Law.
am e,telnpl noses seg
❑ . .B x r c or lickwasom
Owner Date
WORKIE'S COMPENSATION DI!CLARM ION
1 hereby affirm under penally of re jury enc of the following declaration.,
• ❑ 1 have and will mairrin a Certificate or Conant to sell-insure for Worker's
Contpcnsmm,, ax pmvidal for by Sation 171X1 of the Lubar Code, for the
perlmoOne,II me wed far.lcieh Mix permit it sowd. ff,, / _ C>
O 1 have and will maintain Worker's Cnmpereatio�lnytr/ rta q wf A,,2
t]Ild of the Labor Gale,fur the performance af0/; �NhitM1 this penniS is
'ik,uaJ.My Worker''.x..,Co(m�pe)n,minn ln,umncc currfnr nnJ relic tgtytyeOu 2 � /
Canicc��(�,LPolicy Nix:�L (o
CER Ill OF IiKEpIPfION FROM WORKERS'
COMPENSAMON INSURANCE
(rhl,eccrine need nuI b,mntptried if the pcnnit'I,for enc hundred dollars
611X)1 or less.)
I certify that in the pelfnmwnee of She work for which this permit i,issued,1
,hull not employ any person in any teener so is to N,comu mniect to the Workers'
C'unwe'atlon Lawx of Cnlifnrniu.Dow
Applicant
NOTICE TU APPLICANTr If,atter making Shia Cenificme of Exemption,you should
become subject m She Worker's Compensation provlsinm of the Labor C,IJe,you must
Q 0 li omwith comply with ouch pr...lxion.or chi, sencit shall he deemed revoked.
z CONSTRUCTION LENDING AG17NCY
7 1 hereby afro that there is a smomme ion lending agenq for the,dorencc
of the work for which this permit is issued(Sec.3097,Gv.C.)
QLcndcr'x Nano
7 z IsnJcr',Add....
V Q 1 cenify that I have mad this application and wan,that the above inormaion is
l. F.. correct.I agree to comply with ell city and county ordinances and stake laws relating
builha.canarncllon,and hcrchyaothoriee representatives of this city d,enter upon
clic ehovomcncio led PnrPcny for inpraaian puqutxcv
E' y (N'c)egmsmc.indcmnily and Accp hannlcas the City of Cupcnino againa
fq liabilities,jnJ ossa coos and ex ms wheM1 rosy in 'ay mane againm said
V z City in eon, c c of Inc gth' ni /�1 — / a
'� nl'I'LICA 'l1N ERS'I'nN NU 11 MI'LYWITHALLNONPOINT Issued by: � I (/ Date
SOU ' ;IiliGUl..'1'10 S
loth, Dam Re-roofs
na Bn' oi. .lnrERlAls DIscl,osuRE
will Inca am m hmtm mrd,nita'aatp:ml sort m n:Inme haaaNml,mammon Type of Roof
a,deli"ed by tan Cupenlno Munialpul Calc,coupler 9.12,arta IM1c HaJIh sad Sultry
Code.Secio255J21a1] 0 No
All roofs shall be inspected prior to any roofing material being installed.
Will Inespplieantorreture broldingoccepent use cluipirmatordevices which If a roof is installed without first obtaining an inspection, 1 agree to remove
,toil naaardoas air cna0ininm,a,dofined by the Ray coca Air Quality Sit agerncnl
Deas tI all new In terials for inspection. Appical5lunderstands and will comply with
t7 Ye, 0N all non-p ret source relations.
I hove cello,chit n,,mdou,enthesial.myui«menx under Chapwr 695 of the </
Calif rniu lie Ith A Safety Codc.Section,25505,25533 onJ 25531.I delslm d I
if the huilJin oe.not eutmntly nes tarso,doth is myon orobil'ay to notify the
�wcupam of .rtyuirtmen s h the Prior m i....nee of a Certificate of k
°scar'"° � " Signature Ap Ir n Date
rn ent Date All roof coverings to be Class 'B" or better
OFFICE