02100159 CITY OF CUPEWHNO ,�,P-
BUII,DIN(;DIVISION PERMIT ,gNTRR CT0R,IZZ7NF0RMATI0N:,,,
BUIB)Tpgnop(ESSTELLING RD RICHARD HANSET PERMrrN92100159
ow9Ts2N]aMRD HANSET APPLICATTOsPITEV-2002
Ak
OFIIONE'. SANITARY NO. CONTROL NO.
ARCHITECrENGINEER: BUILDING PERMIT INFO
BLDG ELECT PLUMB MECH
0 0 0 0
00 LICENSED CONTRACTOR DECLARATION I��y
a, I hereby affirm that l am licensed under praveionsof Chapter 9(commencing REPLACE WATER
rn<iwim Sectlen7000)of Division 3 nl me business and Pmfcsnions Codc,and my license is
is lull lirree and cllcct.
ZOI., License Class Contractor
Fist♦ ALED
OZ p UaIC Contra[tor ov
�'='t-� ARCIIITECTS DECLARATION
� �a I understand my plans shall M used as public records
=SLC Licemcd Prol'cesiunal
DEC 1 2. 2002
s OWNER BUILDER DECLARA'T'ION
Kt- 1 hereby affirm that 1 am exempt from the Contractor's License Law lir the 6 2 5 0
up 00 following readon (Section 7031.5,Business and Professions Code:Any city it County BUILDING
$250
7
n x$ which requires a permit to construct.alter,improve,demolish,or repair any structure
mor to its issuance,also requires the applicant for such Permit to file a signed smtemem
that he is licensed pursuant o the provisions of the Contractor's Licenm Law(Chaper 9 35j92t2f0S@U@A&G Valuation
m (command ng with Strainn]IXNgol Division J of the RmS ncsx and Promminns Code)or
y
that he is exempt therefrom and the basis for the alleged exemption.Any violation of
Semon 7031.5 by any applicant for a Permit subjects the applicant m a civil Penalty or b UAPNN ccupancy Type
not more man low hundred dollars(S500). 506 — GAS TEST
Lasownerk,the propertlsor mYemntended with wagesumei(Sec.c ,Businem
will do me work,and the swnum is not intended orotfcrcJ for sale(Sec.]fM4,Business
and Professions Code:The Conuamor's Liccme Law rocs not apply to an owner of require nspections
property who builds or improves thereon,and who does such work himsclfor through his
own employers,provided that such improvements arc not intended or offered for sale.If,
however,She building or improvement is said within one year of completion,She owner-
Wilder will have the burden of proving that he did not Wild or improve for purintt of
sale.).
❑I,as owner of the property,am exclusively contracting with licensed conuacton to
ctmsuper the Project(Sec.](104,Busines and Professions Codc:)The Conuamor's Li-
cense Law rocs can apply to an owner of progeny who builds or improves Ihemon,and
gnt,acm lnrsuch Projccu withecontracmr(s)liccnsed pursuant to the Convectors
Law.
eur�(1� nJ9�9tt. B St P C fortis myonWORKER'SCOMPENSATIONDECLA
I hereby allirm under Penalty of perjury one of the following declaratinns:
1 have and will maintain a Cenificsle of Consent sclf-insue for Walker's Compen-
sation,az provided for by Section 3700 of the labor Code,for the performance of the
work for which this permit is issued.
1 have and will maintain Worker's Compensation Insurance,m rcquircel by Staion
3]W of She labor Csde,for be Nitormance of She work for which this permit is issued.
My Worker's compensation Insurance Carrier and Policy number am:
Corea Policy NO.:
CERTIFICATE OF EX EMPr10N FROM WORKERS'
COMPENSATION INSURANCE
Fros section raced not be completed if de permit is for one hundred dollars(Slllo)
coed
I ccnify IM1m in the pcM cc tl tM1c work for which this Permit is issued1 shall net
person d, m
cmployany none n the Workers'Cuir crosation
Laws o^C
shoo
an
� �� u
APPI�r t.
Zol.c subject
A o the Worker
r a atom making this provisions
of the
Exemption.C ,you shouts
1forthh subject y the Worker's Compensation(it tiis Provisium n(the ImMn Crile,you must
D,z forthwith comply with such provisions nr this Pcrmiuhall he deemed revoked.
z O CONSTRUCTION LENDING AG17NCY
't..� Ihereby affirm that there is a cnnsomedon lending agency lin the performance of
z the work for which this Permit is issued(Sec.31)0.Civ.C.)
LL) Q Under's Name
�z lender's Address
V O 1 ccnify that I have mad this application and Bette that the above information is
III F correct.I agree to comply with all city and county ordinances and state laws relating to
Q U building conswction,and hereby authonec epresentativcs of this city to enter upon the
above-mentioned property for inspection purposes.
a
(We)amen to cast.indemnifyexpenses
and keep harmless the City of Cogent admin /:
UN incoiticgmjudgments,cthe granting expmuxmit. may inany wayaccrue against Sid City / r` rl
U z A consequence of the granting of this permit.
l/ v Cy//�
APPLICANT UNDERSTANDS Aryryry��f``///D WILL COMPLY WITH ALL NONPOINT Issued by: Date
SOURCE R{tGULgfION��/ /
zL'11(i,G,]/!tQ®_dd /0 2i OZ Re-roofs
SgIrgnatorco Appherinuu nuamor Da¢
HAZARDOUS MATERIALS DISCLOSURE Type of Roof
Will he applicant tarfurore building occupant Wore or handle hvudous material
as defined by me CoNelinu Municipal Code.Chapter 9.12,and the health and Safety
Cub.Semon 25532(a)? rum All roofs shall be inspected prior to any roofing material being installed.
❑Ycs
Will the applicant or future building occupant use equipment or devices which If a roof is installed without first obtaining an inspection,I agree to remove
11 mit haaardnu.s air contaminants as delincd by the Bay Arca Air Quality Management all new materials for inspection.
District,
❑Ycs �K1
I have mad the huvzrdnus materials requirements under Chapter 695 m the Cali for-
niallcalNAsuelycdc,Scchunc25N15,25533ead2551cl 1 dc's d Setif me building
does not Currently have a enum.Shut it is my resprmsibility m t the occupant of me
m air rq mrnmtst nem mmicsnaneenracemreao� eapacy' Signature of Applicant Date
/O/L 3/O L
All roof to be Class "B"or better
Owncrus amhorind agent Dam