01040055 CITY OF CUPER'I'INO
(WILDING DIVISION PERMIT CONTRACTOR INFORMATION:
BU I I.1)ING AT U RESS: PERMITNO,
18620 STARRETT CT. SAN CARi ns RHFFT 1040099
OWNER'S NAME: APPLICATION Still DAT17,
ONE. SANITARY NO. CONTROL NO.
O-pFhe,�h,
NGINFER: BUILDING PERMIT INFO
kL"m❑ RI.DG ELECT PLUMB MECH
Ni
yP' T,ICENSED C'ON-1 RACTOR'S DECLARATIONatani,mthalIamhcen.ee . JobDeseription
� IX0)of Uivinian.1ofthe Business and Prates.ins code.and Illy license
m y-? J eftccl. -
��w< . -43- 1 IL."�����J_pQ INSTALL A/C @ 2.
ce O o.u Dole (��/.� .J l— G,mmruvS _.
=a. rn 1/-Y Lam` AR(fit rLCI"S DI:c1.AR�TI 5=t
O g undea:md my plain shall be used as public rta,NM`•'
et
r_ r�glMMrwa 1!eV��
to d C O LieenscJ PmRssio,ml
e.�a c find I R BU ooft f DECLARATION C ruION /
11i C breast'ut Btm thus l 1. eamnpt(man,he Cnlonts Co :Anse ty civ thefollow
.1fich m ctrl (Section]omp t.afteo and r e.do tali Code:Any city air away O
ca,xo uM1LM1 I ' '- 1" ill compact. h r I r.l 'lI Y I mm
c. prod I 'lin y t lire II II 'II rl ,]- Ltim.n
° 5th (coin licensed p ualo d pm s f lh t Bust a W (Chapter e
aa,nnhenetna with Section 7000)of Division 3nnne Business and professions Cale) Sy. FI. Floor Area Valuation
or than he is exempt Ih,evir and the husk roc Ih<nllagial esenyninn.Any vinla,lnn or Section]031.5 be,any applicant for a pennil mbjebls the applicant to a chit pen thy
ofhmmnmthan the hundre:ddollam($51p). APN Number Occupanc p
0 t as owner of the ropen,air my,anpoy«a with..,es us their vdc commensalinl,.
will do the walk,and the structure Is not intended or mill for sale(Sca.TW. -
B.sineas tend ptnfe-..iCode ON C...Ae ,..IJ,rrw Lro,does led apply In nth eyulred Inspections
ox' r of pmpeny who wthb,or impmves themon,and xho docs such work himself
or his 204 — UNDERFLOOR FRAME
out...I felt sale.It,howevu.aha building or impm a nenf Is sold within arc stator
completion.the nwnerbuilde will have the burden or proving that he did not build or 01. — ROUGH PLUMBING
in,pmva fa,pue'soc of nale.l-
01.a.nwnerofthepriamlexcMxivelycnmmningwabheenseda(IJILMCIpmto .30r3 — ROUGH MECHANICAL
L,...tune,me pmjen(Sce,7044.Btl'im"anti Prafe'.aan.,Cade:)The Common,. 304 — ROUGH ELECTR I CAL
icense Law dews mot appy In an owner of popery who builds or impmves thcmon.
and who comma¢for such projects with a comntemu%)liccmed purmanl to the 505 — FINAL ELECTRICAL
C'onmmtoru Licon¢I,uw.
fall cxe�,,d,e(r�Se�e. .li&P Chn this rcawm 507 — FINAL PLUMBING
m,�' —tl `1-1&a 506 — FINAL MECHANICAL
w <KIiR'ScoMiS=,,rIONUECLARAII( 514 — FINAL PUBLIC WORKS
nanny ars:n Itmler pennhy.,r perjury m,e or Inc mllowhhg deawrttinall
J 1 have and will maintain a Ccniaeate of Consent in,>elf-insure for Worker',
C'ntractoation, us pu vtied for by Section 371X1 of the,Labor Cada, for the
performance of the work far which this Tomtit is issued,
01 have lend will annurmn wmker'e Compemal I Insurance,air rewired by Section
37W of the Labs Cale,for the performance or the work lot which this permit is
issued,lily Worker's Compensation Insurance carrier and policy number arc:
camas: °* 2policrN :�Ahoo�83973pb
CI3RTIPIC6fIUN I ESEMPI'IUN FROM WORKERS'
COMPENSATION INSURANCE
('This section need not be completed if the rennin is for one hundred dollars .
(5 100)els less.)
T certify Ilial in the pedomumoc of the work far which this permit is issued.I
shad not employ any reason in any mahmer no as to n,x hien In the Workcu'
campM1aalieln rc➢e -le yr -�—�/
Applic:enl �mkuu�
NOIICL'TOA LCA .eft Compensation
rCuohoumail Ulwr,Code.you
Iorom<mbjeeumhcwch risers.prCor„pnsr this povisinhaor the Luton Code. most
O O ILnhwith annuply with such pnrvi.inne or nitie prince shall be deemed revoked.
F V] CONS ere is a combusNDMG AGENCY
Ci .> hnGoy which That there is a issued(Ston[ending agency for the perfnrmanca
^ or the work for wM1ieh Thin pernth i.Ivsual(Sec:Ay)],Clv.C.1
0. lender's Name
� z Lcnda's AJJmc
U O (certify that)]late mind this triplication and slate halite.1hune information is
W Ft'
correct
O V cot.' b n n4IY ' II conj oludynd! ' law,all,nin,
Iinbuilding consumedmand
Wbymainn p t i le,Illll ry In electOin
n< M I ed pent'Iinspection pu,p
0. (w)'6 I l: ' lykcc,,li I.,111.Cil,ofCnn in
V) habeb,ic,luJgncros,cn.l.;told cxpm...
whsh n.ry to any way wcrucagainst sail
V z city in consequence of the Retailing of this pno n.
AI'PhIC NI'UNDr:RSTANDS AND WILL COMPLY W(ITyH�AjLL NON�POIM' Issued by: V �� '/. ��� ��i Date 7
�/?��
501 C !GU \TIONS. L_I Z-D —
urn p _ c m 1 ogle Re-roofs
m UALA turn, Mding ocemardd morhan l
Will y I Ic Chaam or mmm haat Col.arrp >tnre air and nyndna al material Type of Roof
as JCIiSeJny the 32m)?nn Municipal Cale.Chltpmr 9.12.nnJ,hc Ilcal,h:rod S:dcty
Code.Section 255320)'
Dyes 94, All roofs shall be inspected prior to any rooting material being installed.
Will the applicant(it futer<building occupant use r,amaicnl of de,icas x'Mch If a roof is installed without first obtaining an inspection, I agree to remove
oit M¢urdou,air contaminants as derined by the Bay Arca Air Quality hlanagmnenl
)i,nia,'? all new materials for inspection. Applicant understands and will comply with
O yO, ?IIs. all non-point source regulations.
m
T have rued the ha.mdon.Inatcdals my.....near,Itnder Chupwr 6.95 of the
Caliromia Hemth.F Safely Calc,Sections 2!1505.25533 and 25534.1 understand than
lithe building does not courcntly have a r amet.Ind it is my mspmsibildy m notify the
ccupmt of the myalremmns which ams,be loci prior I,ir,aunce nf➢CaniB.atc of
0a0 Y' Signature of Applicant Date
� r'QR All roof coverings to be Class,.B„or better
• nnri4' eg[nl � Dal[
OFFICE