02020099 CITYBUILDING DIVISION
PERMIT CONTRACTOR INFORMATION:
BUILDING ADDRESS: PERMIT N0,
10615 RANDY' LA FERMA CORPORATION 02020099
vNER'S NAME: APPLICATION SUB DATE
ATRICK TSIM 1265 MONTECITO AVE 02/25/2002
PHONE: SANITARY NO, CONTROL NO.
0i . (650) 961-2742
p ARCHTTECT(ENGINEEK: BUILDING PERMIT INFO
200 BLDG ELECT PLUMB MECH
lit
a
LICENSED CONTRACTOR'S DECLARATION Job Description
I hereby afRrm mm 1 am licensed under provi,ions of Chapter 9(commcncinq
„�u9 »AnSecamn7uoolmrumisian3ermeBa,mesvanePrmoslnn.crJe.anamylice^.se DEMO
is in full force and effect.
z 6 License Clan Lic.p
O n u DoleCmuracmr
3 u N ARCHITECT•5 DECLARATION
u. g I understand my plans shall he used as public records
:Se
3 C O Licensed Professional
ca c,,reOWNER-BUILDER DECLARATION
1 hereby offrm that 1 am exempt from the Contmcior's License Law for the
t?¢ following reason.(Section 7031.5.Business and Professions Code Any city or county $8400
Z F p which requires permit t construct.alien mprove,demolish ,m
or repair structure
i 3 _pro t t In req theppficam formch p moutto file a ragned.natement,
thaIh Ic dedl' ction,to the provisionsofmeContractorsLicenseLaw(Chapter9 n pt,� 1p s Valuation
(Commencing.,ith Section7000) f 'Division 3 ofine Bu(meys Pnd Frpfesaone Codc) �`t�i:� 1 ..3j1e UG�.4?7.iU.U:<..1?A IR�J:s
.,that he t exempt therefrom ani the basis for abe.1161etl c..minne.Any violation
-af Scminn 7031-.5 by any ,Items for a permit subjetla the applicanuo v civil penalty
ernes.°or than live hundred dollars(S500). NOAM'TMED INSPEC IONS Occupancy Type
❑I,as owner,of do prupcnY,or my employe,,..In wages as mer sola compensation,
will do the work.and the structureisnot intended or offered for sale(See.701'
'Business aad'Pn,fe„im,s Codev.The Curatorial',Liceme Low docs not opply man Required Inspections”
owner of property Who builds or improves thereon,and who does such work himself ,
or through his own a nplo3_ce'.provided that such impmvemenrs are ata intended or
offered for sale.If,ho» Ibe building or improvement is Id is flurs one year of _.. .-... ....... .. .._._.._ ..... .._ .._. ..-__.... __ .
completion.theowner-h Id ill have the h b f proving that h did of build or i O
improve for purpose of sale.).
_ has r ofthe (Sec.
704 Business
and
Covicenud Contuai to .
^
construct project 1appl to a ownr and Professions Code:)improves
ves tmnor i
y License Law does not apply to an owner of properly who)foe or seimproves thereon,
and who contracts for such projects with commoners)licenud pursuant nodus _ q._ I C ._ _ ._.f..... ... ..._......._ ..... .....,__... . ... ._
Contractors License Low.., �1 1�M L aE® i ,
, ' iy:❑lamexemp de, Sc B&P C far this..,on
..,,
..
caner /l=V ��� 0 2'
'W KER'S Oh1PEN$IASBND[CLARATION MAY 2 S 2002
1 eby affirm underpendtyof perjury rine of fallowing declarations
0 1 have and will maintain a Certificate of Consent to ser-insure for Workers BUILDING
Compensation, as provides for by Section 3700 of the Labor Code. for the
performance of the work far which this permit is issued.
❑1 have and will maintain W'orker's Compensation Inmmna,as required by Section
3700 of the Ladam Code,for the performance of me work for which this permit is
issued.My Workers Compensation Insurance barrier and Policy number am:
4..- .,- ..., .v. _. 1 ... - . .. . - -
Carrer JNow
CERTIFICATION OF EXEMPTION FROM WORKERS J' - 1•' t M11 5� tl'.�s}' t_ Ifi_'1s.<< �A ..s.J.
COMPENSATION INSURANCE"-I
'` t
rota section need am he completed dirt,permit is fm one hundred dollar "
'(SI W)or lcsz.) -
i
rceould mai in the n in
ma n the work for which this permit a issued,I L ;a..,.,
'shall en employ any person ire any manner so as m become subject to me Workers" s '
Applicant on Lawes o(Cvlifnmia.Date
NOTICE'TO APPLICANT'.If,after nuking - Exemption,
_. _ . . _.__._._ ... ... ._ __....._ _....._.. .... .. . _.._ ......_ _ _ .. .. _ .. __ ... .
this Cerin s o or Exempt ion,you should -
Q Obecome subject to the Worker's Compem,,his provisions of the Inbar Craft.you must
forthwith comply with such provisions.,,his permit snail be deemed mvaked.
:tea 'r's'•CONSTRUCTION LENDING AGENCY -"
'"I hereby affiant that there is a construction lending agency for the performance
laz7 ',t ofmc walk for whichthis permit is issued(So.3097.Civ.C.).
Lender's Name'._ ..: :. a..,.,.._ _. .... ... ..... . __.__._.. _._ -_
z Lender's Addiess; ,
U-01 Ccnify mat I have read this application and sum thatthe above information is
W Eta emnect.1 upme to comply with all city and county ordinances and state laws relating
Q V to building construction,and hereby eumorize representatives of this city to enter upon
>a 14 the abuse-mentioned property for,Inxpenlon purpams.,. .- _
U�.t L consequence save,indemngofthikeep
riend. ess me City o(Cupenino egeinst
F (01 liabilities,judgment.costs and expense,which may in any way accrue against said
U sZ. APPLIconsequenceor mANDSAgofmILLCil. '
'APP7:IC NTI ERSTANDS AIC�D�}ILL COMPLY WITH ALL NON-POINT v
so
uR MoritL JSljru-. '1,4* 0Z. Issued by: Date
Signa of it V ortmcmr 3 to Re-roofs
HAZARDOUS MATERIALS DISCLOSURE-
' will ane pplicantmf t bolding compound stoneorh dlehaoural not 'uI Type of Roof.. .. ._ - ..
as defined by theCu;am M p I Code Charter 9.12.and theHealth and sat ty1 -
'can sE)Yesect d3ss3z(M _ - All roofs`shall,be inspected+dp t In ,a
,pnor-to_ariy,roofing material being installed,
Will der,applicant orfuture Wilding ettupentuseequipmentoreevmes.which If a roof is installed without first obtaining an inspection, I agree to-remove
emit hazardous air contaminant as defined by the Buy Area Air Quality Management
Digi ct7 all new materials for inspection. Applicant understands and will comply with
(}' 0Yes :: "° �.' ,. -- all'non-point source regulations,,. _
"as^-•
ha
,;I ve read anhazardous Chic hazous materials requirements'under�Chipter 6.95 of the
califomin Health&Safety Code,Sections 35505.15533 and 35534.1 understand that
-if,he huilof ng des not currently have a tenant,that it is my responsibility to notify the -
ixc0pan f the^iequimments^hich must be,met pdo,t°iarranw'e of a Cenificem of
%= ,orgupvp-L Signature_ of Applicant - Date _
Jolwm a ,,anal'ed,Bent Date/ All roof coverings to be Class "B" or better
OFFICE . _ .. . _.
A s