01020118 CITY OF CUPE RTINO
BUILDING DIVISION PERMIT CONTRACTOR INFORMATION:
H U ILDING ADDRESS: PERMI'I'NO.
SAN FERNANDO AVE. PAT CONSTRUCTION
OWNER'S NAMP909 APPLICATION SUR DATE
2/2001
�PIIONH; SANITARY NO. COMfROL NO.
(9514)228
❑z Z ARC]II'1'LCT/I:NGINL1i R: i! DING PIiRMI I'INFO
OO BLDG ELECT PLUMB MECH
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LIit It,,I a CBNTRAL9Y)R'p DEChvi of Cl0[n Joh Description
0 Z 1 hcehy.1!,it dha I um of
B under p ul Pronx of n,Cash 9lcomy lice Ing
FvCtj with Section elan of Divi,ioniaf the Business unJ Prole eiun,C�W�e/.vend my license
inallBores and effect.
�owU i_icena Class OLio.w Al DEMOLITION
contractoe'S 3 u y Mule_ 1 I�l{fI S IIECLArI2AT3 ��1
CLL g I understand my plane shall be used as public records
p�O I.[r,rr wl Prof...vain -
ce OWNIiR-BUILDER DECIARAI'[ON
lo 1 herehy Minn thud I u empt loon the Connectors Liable Law for the
{=Z¢ billowing fcronn.(Seale 17031!5e[Colonaand Pntfc,siuns Calc Any c ilyor couay
7=O which requires it permit to con.wet,altar,improve,demolish,or repair any structure
I ntno m.....Noir.ul...nn.role,the uppt,ant for,ucth,...adto Hlc r,,igncd sdmemau
thin heisIn ordpaanent ,,hepro,Lmmnrtn,Conmraor,Lian�law(cnapdnq Sq. Ft. Floor Area Valuation
(commencing with Section]01)B)ofDivision 3 of the Busing,and Professions CWe) _
on than he'In ;thererrtnl and ohc nasi,for ole alleged exe.nplion,Any vinlntiun
f Seri mr 0031top.5 M'any appli..l fora permit olnec6 the applicum nr a roof penalty
oma nn agllnr:cnundaddollars(s500) APN Number Occupancy ype
❑I,a,owner of the property,m my employees with rages a,garotte cnmpemalinn.
will it,,he xnoak,and the nlnr,mrc 1,nil imendcd nn offered for s lc(See.TW4, 00
business sad pore„don,Cale:'I he Cmnrarinr,urelt,e Law doo,m,l apply loan Required Inspections
ownerof pmpcny Who builds or improves thereon.and w'ha does such work hownwiI
in though Ills own nupluyces,provided Ihol well imp.........ite are Bud intended nr
nrerredforsale.If.ht, %thebodelingn mpg eln ,oldwiginteyearol NO ASSIGNED INSPECTIONS ..
tdclinn, he nal....budder will have the or
of pro Ing Ill.,he did not build or
mpmwe for om,ow oI ale.),
❑I,as ow nor nl'thc property,;an exdo,wely connoting with F....ed contractor nr
construct Inc mejeel(SIL.71104,Insure,,mad profe, ,Co Ic:) Ila Contrucmr',
License Low does not apply man owner m progeny who build,or improves la moon.
CnA won tons Iia such pntjm s .In a u...lo m(s)licensed par and m the
omment,i'iccn,c law.
❑1 am exempt under Sec. .H m P C for this reason .
Owner Dae cp
WORKER'S COMPENSArRON DECLARATION 2
I hereby aBirm under penally of perjury,one of the following decimations:
❑ 1 base and will noaidann a Cendicae of Consent to sel Gimme For Worker's
Compematfon, as provided for by Section 3010 of the I.aNn CWe, for the 7.
perf(.nnune,it the work our which m,p'mail Is issued.
❑1 have and will maintain Worker's Coirremation Insurance,as required by Section \
37N)of the Imhor Code,bin the le,I aa,e of the work In whish k s panto is
issued.MaywWorker'lss CC`ontre%mm ationn Insurance carrier and Policy number are:
Pillarrier:Jj q,IIrICiTi I(IY pIrXll I,,y No N FROM 1'� OR KERS'
COMPENSATION INSURANCE
(Thi,section need Bat be conal if the permit is for one hundred dollars
IS 1001 or less.) ,
I cend,)hal in the performance at the work far which this p.it is issued,I
,hall not employ any person In any m;mncr at'e,to necmne san)rn m he Worker,' .
Campema ter Lass of California.Dae
Applicno I
NOTICLr TO APPLICANT:If,after making this Ceailicae of Exemption,you should
Mcmne whNO to the W'orlars Compen,alion provision,of the Lather Colt,you must
Q O Imgwinl comply will such pre loons an oris per ell Shull be deemed rooked.
Z
^F ti CONSere s n ION IA?LADING AGENCY
I weak
No uRchrin that resit I,i...edcolva (Set. dcnoing agaay for dm pafinmunee
0 of Leader
xnrk Inn which his permit is iuueJ(Sec.JII9l.Civ.C.)
Under',Name
Lender',Address
U I cenify thin I have road0n,applicmio i and late that the cKol,lot a, n i,
k. E. correct.I agar u.comply with.11 city and cowuy on inaaces and Banc law,relaling
U to building construction.and hereby aulhorirc mpmsenwtives of this city to ender upon
�y W nteann,e-neotiored pot ny lbnlnspa'lin i Pugnrmn.
F, y (We)agree In saveindenmily and Aas cs..the Coyof Coleman,aquina
Jl Iiabilities.ludgmems,tush and cam ah muY any way:acme uguimt suit
U Z Cro,It cnlMgt'l'f'o”of the I Iles aft ,"i''oll
APPL7(Jey. .,.ERS ILL MP WITH,IIy.�iN�POINT ��Z�O
s CE • .nTIssued by: Date
. gnawre rel,pp .gnu'tel a — - — Z/Dade Re-roofs
IAZnI S ATHRIALS DISCLOSURE
Will the 1p,liw; I,dKiary balding sampan some m handle incomes i,maenad Type of Roof
o defined by the Cupenina h�ipal Code.Chapter 9.12 and the health and Safety
Codd,Sill 25532110"
°Yce No All roofs shall be inspected prior to any rooting material being installed.
Will the appl'aantlirtondosmiIll goralpans uwano,ocanmd,,we,,hien If a roof is installed without first obtaining an inspection, I agree to remove
emit haardtus it ctmanina -defined by the Buy Arca Air Quality Manager em
. Distrierr all new materials for inspection. Applicant understands and will comply with
Cl Ye, No all non-point source regulations.
1 dive red IM hnrerdnu,maarivl,requirensms under Chupar 6.95 or the
California Health N Safety CWe,Sections 255115. '1 undcraand gel
Fine nuilJingfres not curremly hal mans t it ie roba,p:nibilily w nelifylhe
Oceurnnl rel .r,gtr mels w dust be duel Prior c of u Cu cud.
tematurc of Applicant Date
owmerm7mahen..eaagent Date All roof coverings to be Class"B" or better
OFFICE