02080118 CUPTI
etBUI DING DIIVIIISSIIONNOPERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT NO.
19055 PENDERGAST AVE GREAT LAND CONSTRUCTION CORP 02080118
'pJNUDYAWANG 1019 S DE ANZA BLVD APPLICATION
PHONE: SANITARY NO. CONTROL NO.
(408) 865-0562
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M.Z ARCHITECf/ENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
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Z 5 m 8 LICENSED CONTRACTOR'S DECLARATION Job Description
Ilion 70 ))or madam licensed under P and
Prunaof Chapter9(commencing TRUSS GALES--IN HOUSE USE ONLY
�w F� with Section 700))nTDivision lorthe Business and Profcxsiuna Calc,and my license
�<'2 is in fall foresaw effect. (ORIGINAL #01120100)
s a License Class Lit.A
O i O Nit Contractor /
w 3 a}-n ARCHITECT'S DECLARATION \ •�
1 understand my Plans shall W used as public records c\\
Licensed Professional \�
OWNER-BUILDER DECLARATION
w=,� I hereby affimt Nat 1 am exempt from the Contractor's License law for the
C?< following...(Section 7031.5.Business and Professions Code:Any city or county
I SF C which requires a Permit toe construct,after,- pro demolish, p y.wcwre
63cm_a-S prior is issuance.also acquire,the f such Permit fl signed statement - -- - -- -
Oat heglicensed puisaannothepboivmssoftheCotractors License La (Chapter9 / Inn
S Ft 7 n Flo .r•Area ,, 1 Valuation
(commencing,`vith Seca;-70001 of Division J fthee m and Profession,Codel \,t)','1�j'(i!�l9'1.t,•r r'a {••-at i s a t m:lryl l'.i L7.+;
or Nat he exempt mcrcfrom and the hosts for the allege)exbmpuob.Any violation
of Section 703 h5 by any applicant for a Permit subjens the avpl.i.11.a civil pcnalry
n or not mom man five hundred dollars($500). APN Number Occupancy Type
❑I.as owner of the Property,or my employees with wages as their sale compensation, 101 -
will do'the admk and the'swctureis not intended or offered'for sale(See.7t . 10 2 - PIERS Required Inspections;,'-'
'Business and Professions Code:The Conuacmr's License law does not apply to an Q
owner of property,Who builds or ins mmat thcaon,and who does such work himself 103 - UFER _
or through his own employees.provided that such improvements arc not intended or _. .
"-offered'err'sale.IL however,the building or improvement k sold within one year of 104 - - REBAR `` '"b :t.
impletion,the owner-Wilder will have the burden of proving that he did not build or
completion,
far puryor,of rale.). 105 - ANCHOR BOLTS
...0-Les r1w�«rdthe r:6iKny.oro�.-iioivdy aam7m;iiiti w:imrcer.:�d comovzo'<m_ ---,. .-..... 106 ..SEWER. ..&...WATER
---:'----._-'-r- -:-�;---._._...-- -- -
construct the proper(Sec.7044.Business and Professions CcOr)The Cammmora 202 - UNDERFLOOR PLUMBING
_. - License Law does not apply to an owner of apro,sucycome who builds se improves,credo.
_ _. ..anewctorsLicenseLaw.such.proj tr.wim.arontr m al.li<n ap actor,-me _. ._.._.......2-03- -' UNDERFLOOR -MECHANICAL--- - --
oi:me.rplevnaesec. :BePCfee mi.areason 204 - UNDERFLOOR' 'FRAME",
ownar D,te ' " 205 UNDERFLOOR INSULATION
WORKER'S COMPENSATION DECLARATION 301 - ROUGH PLUMBING
� _
_- - - IlterebyaRrmunder peoultyofpeyulyoneorNefollowing declaration, 302 - TUB & OR SHOWER
❑ 1 have and will mi btcerdfidam of Consent',self-m.aare for worker's 303 - ROUGH MECHANICAL
- Compensation, as provided for by section 37M of the labor Code, for the 304 - ROUGH ELECTRICAL
performance of the work for which this perm is issued. ,
❑I have ana'wiu'maintain worker's Compensation Inramrte.as requires by Seddon 3 05 - FRAME
3700 of Lahr Cook,for the performance of the work for which this pemrit is 3 06 - HOLDOWNS
My Worker's C pe afon Insurance tamer and Policy number am. .,
_ 307 INSULATION,
but d . , _:,. ..---. .. _ . _ ...._. . „ .. .
No i
Cum r4 1 I if
01:EXEMPTION FROM WORKERS',
a Ll (n� � f368 -r�LSHEETROL_''Ka '
COMPENSATION INSURANCE-"._,: ,...- - ------'30'9-:--•:-EXTER-I OR--LATH-=--'----' --'--_---
(Then need nm W completed I mm
e perit is f one hundred dollar: 3 10 - INTERIOR LATH 1 .
(slwlnrtea..1 311 -- SCRATCH- COAT
-"y I certify that in the performance of the work for which this permit is issued,I.
shall not employ any person in any manner so as to become aahject m the Workers: 313 - ROOF NAIL' '
Compensation Law.,of Calimmin.Da1e 501 - . FINAL FINAL ELECTRICAL.-ENERGY. ._
.'Applicant. -- ._ .. .
NOTICE TO APPLICANT:If,after makingthis Cenitieacor Esemptionyou should 502 - FINAL PLUMBING ENERGY
Q Q fmmneh bjro o thin such
Com this atom of the Luhur Code.you must
Z noir pro"rsballWdeemedresume. 503- FINAL MECHANICAL . ENERGY
soul
wit pywi provisions or pc -
� m coNsTPucIONLENDING AGENCY 504 - FINAL BUILDING ENERGY.
1 h b tram thath on t cti n lending agency for the performance
CLS ohne work for which hispz _t . orada(See 3097 Co.C.) 505 - FINAL ELECTRICAL
aq L c a'nade.. --506 - GAS TEST - ' ..._. . .
_ 'U.O I Bendy mat i nave read arra avvue.00n aha arm mat me:nave inwm,ation rat 5 0 FINAL PLUMBING '
'2nrrcn.I agree m comply with all city and coumv ordinances and.tate laws relating 5 - I NAL M CHAN I CAL
'Q U t to building construction,and hereby authorize representatives of this city to enter upon 5 9 - INAL DE
Phe aMwe-mentioned proPeny for.inspection purposes.
F y (We)Sgrtetosave.indemmyand keep hmblessthe CityofCaperto,against 51 - INAL
UVi liabilities,judgments,costs and expenses which may in any way seems against said
z City in consequence or me granting of permit. 514
_'� APPLICANT UNDERSTANDS AND WILL COMPLYWITH ALL NON-POINT Issued by- Date
SOURCE REGULATIONS. - . y
Signamrt of Applicant/Cdnmacmr Date Re-TOOT$
.HAZARDOUS MATERIALS DISCLOSURE
WII'theapplicant orf rare budding weapon Wort or handle h,zvdous memerial Type of Roof
as dermed by the Cupenmo Municipal Code Chapter 9,12, ad the Health and Safety s , r : 1 v. -` i i s '.' s i I f 7 As• `
Cale SOcYon 25p5J (1 (. ON iJ1'I .tf r.
All roofs shall be inspected prior to any roofing material being installed.
: -
WBth pplcard..or int Nil dair ocsuper use ed,.topment or de anen If a roof is installed without first obtaining an inspection; I'agree to remove
em thazard, contaminants as defined by the Bay Area Air Quality Management
Disnict3 all new materials for inspection. Applicant understands and will comply with
uvea" - ON. - all non-point source regulations.
1 have read the hupardous mmenuH muircmems under Chapter 6.95 of the
Cilimirm.Health&Safety.Cale.Sections 25505,25537 and 25534.1 understand than
,if Ne building does not currently have a mnam:mm itis my responsibility ui notify he
occupant of the rcquiremrnu which must W met prior to issuance of a Comficac of
Occupan`, Signature of Applicant .. - _- _. Date _
'owner ar.amorieea agent Dam All roof coverings to be Class "B" or better
OFFICE